MAKUENI COUNTY HIV, AIDS & TB STRATEGIC PLAN
2015/16 – 2018/19 Published by the County Government of Makueni
© Copyright 2016 “For posterity of generations, the future of Makueni is in our hands” Table of Contents
Abbreviations vi - vii
List of Figures and Tables viii
Foreword ix
Acknowledgements xi
Executive Summary xii
Chapter 1: Background 1
1.1 HIV, AIDS and TB Planning and Implementation 3
1.2 HIV and TB Financing 3
1.3 HIV Policy Environment 3
Chapter 2: HIV, AIDS and TB Situation Analysis 4
2.1 National HIV and TB Overview 4
2.2 County HIV and TB Profile 5
2.3 HIV and TB Programmatic Gaps and Challenges 7
2.4 SWOT analysis 10
Chapter 3: Rationale, Strategic Plan Development Process 11
3.1 Rationale 11
3.2 Guiding Principles 12
3.3 Strategic Plan Development Process 12
Chapter 4: Vision, Mission, Objectives and County Strategic Directions 14
4.1 Vision 14
4.2 Mission 14
4.3 Objectives of the MCHTSP 14
4.4 County Strategic Directions 15 4.4.1 Strategic Direction 1: Reduce New HIV and TB Infections 15
4.4.2 Strategic Direction 2: Improve Health Outcomes and Wellness of TB patients and People Living with HIV 31
4.4.3 Strategic Direction 3: Use a Human Rights Approach to Facilitate Access to HIV and TB Services 42
4.4.4 Strategic Direction 4: Strengthen Integration of Community and Health Systems 45
4.4.5 Strategic Direction 5: Strengthen Research, Innovation and Information Management 48
4.4.6 Strategic Direction 6: Promote Utilization of Strategic Information for HIV and TB Programming 49
4.4.7: Strategic Direction 7: Increase Domestic Financing for Sustainable HIV and TB Response 51
4.4.8: Strategic Direction 8: Promote Accountable Leadership for Delivery of MCHTSP Results by all Sectors and Actors 53
Chapter 5: Monitoring & Evaluation Plan 55
5.1 M&E systems 55
5.2 Data Quality 55
5.3 Baseline Information 55
5.4 Indicators 55
5.5 MCHTSP Reviews 55
5.6 Data Flow and Archiving 56
Chapter 6: Coordination and Implementation Arrangement 57
6.1 Stakeholder Management and Accountability 57
6.2 County Committees 59
6.3 Critical Assumptions 60
Chapter 7: Risk and Mitigation Plan 61
Chapter 8: Costing and Resource Mobilization 63
8.1 Projected Cost of HIV Programming 64
8.2 Financing the MCHTSP 65
Annexes 66
Annex 1. Results Framework 66
Location of Makueni County 75 List of Figures & Tables
Figures Figure 1.1 Makueni County map Figure 2.1 New HIV infections Figure 3.1 MCHTSP alignment and linkages Figure 4.1 Combined approach interventions Figure 4.2 County TB response Figure 4.3 Makueni County health and community systems integration model Figure 5.1 Data flow for County HIV and TB response Figure 6.1 County Coordination infrastructure for HIV and TB plan delivery
Tables Table 1.1 Key County parameters Table 2.1 County HIV profile Table 2.2 Trend of County TB Outcomes Table 2.3 TB case findings Table 2.4 Programmatic gaps and challenges Table 2.5 SWOT Analysis Table 4.1 Interventions utilizing combination approach in targeted populations Table 4.2 Interventions to maximise efficiency in service delivery through intergation Table 4.3 Interventions to leverage on other sectors to reduce new HIV and TB infections Table 4.4 Interventions to reduce new TB infections Table 4.5 Interventions to improve health outcomes and wellness of TB patients and PLHIV Table 4.6 Interventions to improve health outcomes of people with TB Table 4.7 Intervention for using human rights based approach to facilitate access to HIV and TB services for PLHIV and TB patients Table 4.8 Intervention to strengthen intergration of community and health systems Table 4.9 County research priorities Table 4.10 Interventions to strengthen research, innovation and information management Table 4.11 Interventions to promote utilisation of strategic information for HIV and TB programming Table 4.12 County health budget allocation trend Table 4.13 Interventions to increase domestic financing for sustainalbe HIV and TB response Table 4.14 Interventions to promote accountable leadership for delivery of MCHTSP results by all sectors and actors Table 6.1 Stakeholders’ roles and responsibilities Table 7.1 Risk and mitigation plan Table 8.1 Baseline information utilized in this model Table 8.2 MCHTSP resource needs vi Abbreviations and Acronymns
ACUs AIDS Control Units CHEW Community Health Extension Worker
AFB Acid Fast Bacilli CHTC County HIV and TB Committee
AHF AIDS Health Foundation CHVs Community Health Volunteers
AIDS Acquired Immuno Deficiency Syndrome COBPAR Community Based Programme Activity Reporting ANC Antenatal Clinic CPT Cotrimaxazole Preventive Therapy APOC Adolescent Package of Care CSO Civil Society Organization ART Anti-Retroviral Treatment/Therapy CTLC County TB and Leprosy Coordinator ARV Anti-Retroviral Drugs DHIS District Health Information System BCC Behaviour Change Communication DOT Direct Observed Treatment cART Combined ART DRTB Drug-Resistant TB CASCO County AIDS and STI Coordinator DSTB Drug-Susceptible TB CSOs Civil Society Organisations DWA Dominion of World Agriculture CBHTS Community-Based HTS EBI Evidence-Based Intervention CBO Community-Based Organization Emtct Elimination of Mother-to-Child Transmission CBTBC Community-Based TB Care ETR End Term Review CCC Comprehensive Care Centre FBO Faith-Based Organization CEC County Executive Committee FM Fluorescent Microscopy
FSW Female Sex Worker
HBC Home-Based Care
vii HBTC Home-Based Testing and Counseling OIs Opportunistic Infections
HCBC Home and Community-Based Care OJT On-the-Job Training
HCW Health Care Worker OPD Out Patient Department
HIV Human Immuno-deficiency Virus OVC Orphans and Vulnerable Children
HMIS Health Management Information System PAL Pulmonary Approach to Lung Health
HR Human Resources PEP Post-Exposure Prophylaxis
HTS HIV Testing Services PHDP Positive Health, Dignity and Prevention
ICAP International Centre for HIV and AIDS Programme PITC Provider Initiated Testing and Counseling
ICF Intensify Case Finding PLHIV People Living with HIV and AIDS
IEC Information, Education and Communication PMTCT Prevention of Mother-to-Child Transmission
IMCI Integrated Management of Childhood Illness PPM Private Practice Mix
INH Isoniazid PrEP Pre-Exposure Prophylaxis
IPC Infection Prevention and Control PwD People/Persons with Disabilities
IPT Isoniazid Preventive Therapy PWID People Who Inject Drugs
IPV Intimate Partner Violence SCACCs Sub-County AIDS Control Committees
KAIS Kenya AIDS Indicator Survey SD Strategic Direction
KASF Kenya AIDS Strategic Framework SGBV Sexual and Gender-based Violence
KDHS Kenya Demographic and Health Survey SGR Standard Gauge Railway
KP Key Populations SRH Sexual and Reproductive Health
LMIS Logistics Management Information System STI Sexually Transmitted Infection
M&E Monitoring and Evaluation SW Sex Workers
MCHTSP Makueni County HIV, AIDS and TB Strategic Plan SWOT Strength, Weakness, Opportunities and Threats
MDAs Ministries, Departments and Agencies TAT Turn-Around Time
MIPA Meaningful Involvement of PLHIV TB Tuberculosis
MoH Ministry of Health TBA Traditional Birth Attendants
MOT Modes of Transmission TIBU Treatment Information for Basic Programme
MSM Men who have Sex with Men TOWA Total War against AIDS
MSW Male Sex Worker TSC Teachers Service Commission
MTR Mid-Term Review TSR Treatment Success Rate
NACC National AIDS Control Council TST Tubercullin Skin Test
NASCOP National AIDS and STI Control Programme TTIs Technical Training Institutes
NBTS National Blood Transfusion Service TWG Technical Working Group
NCD Non-Communicable Diseases VL Viral Load
NGO Non-Governmental Organizations NTLD National Leprosy, Tuberculosis and Lung Disease Program Program
viii Foreword
HIV, AIDS AND TUBERCULOSIS continue to be epidemics that do not only claim many lives, but also put a significant amount of strain on financial resources in treatment and management. Efforts to combat these challenges have borne fruit as Makueni County continues to realize a steady drop in new infections and deaths. Cognizant of the enormous challenge that lies ahead, the County Government has developed a proactive intervention strategy to creatively respond to these challenges. This four-year Makueni County HIV, AIDS and TB Strategic Plan (MCHTSP) provides a holistic County approach to the HIV, AIDS and Tuberculosis response. The Strategic Plan has been developed through the collaborative efforts of the County Government of Makueni, the civil society, the faith sector, the private sector, the networks of PLHIV, the networks of PLWDs, Youth representatives, and the implementing partners.
The County has so far established 57 new care and treatment centers, 72 new PMTCT sites, revamped the School Health program, strengthened the partner-supported drop- in centers along the Nairobi-Mombasa highway addressing issues of the Key Populations and strengthened the HIV-in-workplace interventions among others. With this Strategic Plan, we are confidently assured of contributing to the global vision of zero new infections, zero HIV related-stigma and discrimination, and zero AIDS-related deaths through combined prevention approaches, population-driven strategies, geographical prioritization for specific interventions and using a shared responsibility approach. The County leadership, in partnership with the national government and other stakeholders, continues to address using a Human Rights approach the many socio- economic challenges resulting from HIV, AIDS and TB. Notably, the County will strive to mobilize domestic financing for HIV, AIDS and TB programming, taking into account the limited County fiscal space, other competing priorities and the dwindling donor support. We deeply believe that this Strategic Plan will guide the implementation of the HIV, AIDS and TB response to achieve the highest attainable healthcare for all the people of Makueni as enshrined in the Constitution of Kenya 2010.
Prof. Kivutha Kibwana Governor Preface
THE MAKUENI COUNTY HIV, AIDS AND TB STRATEGIC PLAN (MCHTSP) 2015/16-2018/19 constitutes an integrated and multi-sectoral response to HIV, AIDS and TB. The Plan is designed to provide adequate space and opportunities for Communities, Civil Society Organizations, Faith Sector, Private Sector, Schools and Academic Institutions, Health Care Facilities, Implementing Partners and County Government Departments to actively participate in the implementation based on the individual stakeholder’s mandate and comparative advantage.
The MCHTSP has been developed through a very participatory and consultative process that reflects the aspirations of the people of Makueni in their efforts to fight the scourge of HIV, AIDS and TB. This Plan will support implementation with meaningful involvement of communities, PLHIV and civil society organizations.
I therefore urge all the stakeholders to formulate and implement innovative intervention plans that are aligned to the MCHTSP. It is my sincere hope that all stakeholders shall join the fight against the HIV, AIDS and TB epidemic, through concrete MCHTSP guided interventions to achieve the objectives of the various strategic directions.
Dr. Andrew Mulwa, ECM – HEALTH SERVICES Acknowledgement
THE MAKUENI COUNTY HIV, AIDS AND TB STRATEGIC PLAN (MCHTSP) - 2015/16 - 2018/19 is the first combined strategic plan developed to tackle HIV, AIDS and TB epidemic in the County. It is aimed at synergizing the response in a way that will significantly maximize on the scarcely available resources and provide the guidance for addressing HIV, AIDS and TB epidemic in the County by all stake holders.
The plan was developed through a thorough multi-sectoral consultative process that involved many sectors of society and various partners. We wish to thank all those who found time and offered resources towards the process of developing this strategic plan. In particular, we thank the Directors of The Department of Health Services and the County Health Management Unit Heads for the enormous efforts put towards realizing this ground breaking strategic document.
We appreciate the support from the National AIDS Control Council (NACC) through the regional office for the technical and financial support during the drafting, review and validation of this important document. We also thank the Drafting Team for their selfless efforts and zealous dedication to come up with the excellent document. We also thank in a special way the Technical Support Team for reviewing and finalizing the document in the stipulated time frame. We as well recognize the immense contribution of the Sub-County Health Management Teams, the various supporting and Implementing Partners especially ICAP-K for the technical and professional input as well as all the stakeholders from all spheres of Society who tirelessly participated in the development of this Strategic Plan.
Special tribute goes to the team of representatives from The Association of People Living With Disabilities of Kenya (APDK), The Networks of People Living with AIDS in Kenya (NEPHAK), the Faith Sector, The Civil Society Organizations (CSOs) and the Youth representative. It is from these engagements that we developed a four-year working plan to achieve the County HIV, AIDS and TB strategic objectives.
This Strategic Plan would not have been complete without the inputs from the Various County Government Departments in particular Agriculture, Social Services, Information and Technology, and Education who provided vital statistics, data and information.
Finally, we acknowledge in a very special way the great People of the County of Makueni for the opportunity to serve them and to whom this document is dedicated.
DR. PATRICK KIBWANA CHIEF OFFICER, HEALTH Executive Summary
Makueni is clustered as a medium-burden, medium-incidence County, with a HIV prevalence rate of 5.6%. The prevalence among women is higher (7.6%) compared to that of men (3.3%) (NACC 2014 estimates). HIV and TB co-morbidity poses a serious health challenge, impacting negatively on labour and productivity. The MCHTSP is informed by national strategies including the Kenya AIDS Strategic Framework (KASF 2014/15-2018/19) and the National Strategic Plan for TB, Leprosy and Lung Health(2015-2018). The purpose of this plan is to inform policy formulation on HIV and TB response, implementation of HIV and TB interventions and serves as an advocacy tool for resource mobilization and allocation. Guided by the principles of equity, people-centredness, inclusivity; multi- sectoral approach; efficiency; social accountability; integration (HIV and general health) and evidence-based programming, the MCHTSP has the following eight Strategic Directions: 1. Reduce new HIV and TB infections. 2. Improve health outcomes and wellness of TB patients and people living with HIV . 3. Use a human rights-based approach to facilitate access to HIV and TB services. 4. Strengthen integration of health and community systems. 5. Strengthen research and innovation to inform the MCHTSP objectives. 6. Promote utilization of strategic information for HIV and TB programming. 7. Increase domestic financing for a sustainable HIV and TB response. 8. Promote accountable leadership for delivery of the MCHTSP results by all sectors and actors. The MCHTSP is a four-year guide with clear deliverables, performance indicators and targets. Implementation of this Strategy will go a long way in contributing to the health of Makueni residents, raising their economic productivity as well as contributing to the wider realization of the Vision 2030. xii Chapter 1 Background
Makueni County is located in the eastern part of Kenya with its headquarters at Wote town. The County is endowed with: MBOONI
KAITI 1. Natural resources such as forests, wildlife, minerals, MAKUENI building sand, water (rivers), KILOME pasture and farming land. 2. Tourist attractions such as Kyulu Hills and National Park, part of Tsavo East National park and historical sites. 3. Main economic activities KIBWEZI WEST include subsistence agriculture, beekeeping, small- scale trade, dairy farming and limited coffee growing and commercial businesses. KIBWEZI EAST
The County is faced by a growing population, water scarcity and falling food production among others.
Density People per km2 N 62 114 148 199
Fig 1.1: Makueni County Map
1 Table 1.1: Key County parameters
Category Description
Location and size 8,034.7km2; borders several counties; Kajiado to the West, Taita Taveta to the South, Kitui to the East and Machakos to the North. It lies between Latitude 1º 35´ and 30º 00’ South and Longitude 37º10´ and 38º 30´ East
Administrative units Constituencies: Mbooni, Makueni, Kaiti, Kibwezi East, Kibwezi West and Kilome
Population (2015 projected) Male – 468,297; Female – 493,442. Total 961,740
Educational institutions ECDE centers – 1,510 Primary schools - 982 Secondary schools - 339 Tertiary institutions -12 Primary school net enrollment rates - 58.6%; Drop-out rate - 3% Secondary school net enrollment - 50 %; Drop-out rates 5%
Health facilities 223 (Source RHIS)
Immunization coverage 62.26%
Contraceptives acceptance 30.75%
Morbidity rate 33.6%
Mortality rates Infant Mortality 53/1000 live births (National - 54) Under five mortality - 61/1000 live births (National - 79) Maternal mortality - 400/100,000 live births (National - 495) Crude death rate - 11.9/1000 ( National - 10.4)
Doctor-patient ratio 1: 22, 217 against WHO recommendation of 1:10,000
Nurse-patient Ratio 1:2,197 against WHO recommendation of 1: 1, 000
Poverty indicators Absolute poverty - 64.3% Food poverty - 57.2% Poverty is prevalent in the County and manifests itself in other socio-economic outcomes such as poor nutrition, health, and education, as well as a lack of access to basic services
Human Development The County scores a 0.56 on the HDI — a composite measure of development that combines indicators Index (HDI of life expectancy, educational attainment and income. This is at par with the national average.
Socio-economic Agriculture is the main source of income in the Makueni County and accounts for 78% of the total household income. Populations living in the lowlands of the County engage more in fruit farming while those in the highlands grow maize, millet, tubers and rear dairy cows. Communities bordering the coastal region mainly rear traditional cows and goats. Since Makueni County is classified in the Arid- and-Semi-Arid region category, farm productivity is very low.
Source: Makueni CIDP 2013
2 1.1. HIV, AIDS and TB Planning and Programme (MAP), and its project KHADREP Implementation (2000-2007) and TOWA (2008-2014), which supported community based HIV interventions Prior to Devolution, HIV and TB planning and HIV and TB commodities in the county were coordinated centrally through national through the national government .The Global strategic plans. The implementation has been Fund to Fight AIDS, Tuberculosis and Malaria through several structures including facility (GFATM) is another funding mechanism that based structures (dispensaries, health centres, is supporting HIV and TB programmes in sub-county and county hospitals, private Kenya and in the county, and complements and faith based facilities); community based the ongoing efforts by multi- and bi-lateral interventions through the CSOs and community agencies, and by the government1. units and work place interventions through AIDS Control Units (ACUS). The National AIDS Control The national donor dependency scenario is Council established multi-sectoral District reflected at the county level with Partner Technical Committees (DTCs) and Constituency contributing a higher proportion. Currently AIDS Control Committees as coordinating most of the ongoing facility based HIV programs structures. However the DTCs were disbanded in the County are financed by International and 6 CACCS (referred to as Sub County AIDS Centre for HIV and AIDS Programme (ICAP). Coordinating Committee (SCACCS) have been For instance, ICAP supports 176 HIV HCWS established and are functional. In facility and 32 peer educators, AHF supports facility based HIV and TB response, the County has and community based HIV interventions in four the County AIDS and STI coordinator (CASCO), sub counties namely Kilome, Kaiti, Kibwezi County TB and Leprosy Coordinator (CTLC) and East and Kibwezi West. Key Population 6 Sub CASCOs and 6 Sub CTLC respectively. programming is supported by UoN MARPS Project and World Provision Centre along the Nairobi – Mombasa Highway, Nutritional 1.2: HIV and TB Financing supplements for TB patients are supported by Over the years, implementation of the HIV and AMREF while Community based interventions TB programmes has heavily relied on donor are supported by CSOs out of pocket financing. support. Donor funding to health and HIV and The County has a health budget with no TB has been channeled through either the specific budget line for HIV and TB. government budgetary system commonly referred to as on-budget or through the extra- 1.3: HIV policy environment budgetary – off-budget, mainly directly from donors through donor administered project/ The constitution and legal framework form programmes or through NGOs without going the base around which all actions are defined. through the Government budget process. The Though health is a devolved function, the national extra-budgetary allocation by donors is by far government formulates policies, guidelines larger than the on-budget support and has been and legislative frameworks through which all growing over the years. The donor categories health programmes are to be implemented in comprise both multi-lateral and bilateral the country. HIV and TB response in the County agencies, and include funds made available is therefore guided by these national policies, through the World Bank Multi-Country HIV/AIDS guidelines and legislations.
1 Kenya National AIDS spending assessment report for the financial year 2009/10-2011/12
3 HIV, AIDS and TB Situation Chapter 2 Analysis
HIV, the virus that causes AIDS is one of the world’s low in many countries compromising the efficacy of most serious health and development challenges. TB Control efforts2. About 36.9 million people worldwide are currently living with HIV. The vast majority of these people are in 2.1 National HIV and TB Overview low income countries, particularly in Africa. HIV and 2.1.1 HIV and AIDS in Kenya tuberculosis (TB) are so closely connected that their The HIV epidemic in Kenya is both generalized and relationship is often described as a co-epidemic. In concentrated in some populations. The national the last 15 years the number of new TB cases has Prevalence stands at 6.0%3. The MoT survey of 2008 more than doubled in countries where the number of outlines the sources of new infection as per the figure HIV infections is also high. TB case detection remains below.
Figure 2.1: New HIV Infections
2 Public Health Report Journal 2005 May-June Edition 3 KASF 2014/15 – 2018/19
4 2.1.2 Tuberculosis in Kenya Within Africa, Kenya was the first country to achieve WHO targets for case detection and treatment success. This was made possible by sustained government HIV& commitment, evidence based innovations, adoption TB and roll out of new diagnostic technologies and aids strong partnership. However, challenges exists in TB response include; limited capacity for commodity management, financial gap for TB control, limited prioritization of TB control and prevention in counties of manpower and productive time. Generally HIV and the shifting epidemiology of TB4. and AIDS has affected all sectors of the economy in the county as a result of absenteeism, sick offs and deaths. The caring for the sick leaves less time for 2.2 County HIV and TB profile work while high costs of treatment means resources 2.2.1 HIV Profile are diverted from productive use. HIV and AIDS remain a big challenge due to its Makueni is clustered as a medium burden, medium devastating effects. In Agriculture, where 78 per incidence county with prevalence of 5.6%. The HIV cent of the rural population derives their livelihood, prevalence among women is higher (7.6%) than that the pandemic has reduced productivity through loss of men (3.3%) (NACC 2013)
Table 2.1: County HIV profile5
Indicator
Total population (2013) 930,530
HIV adult prevalence (overall) 5.6%
HIV prevalence among women 7.5%
HIV prevalence among men 3.3%
Number of adults living with HIV 22,100
Number of children living with HIV 3,372
Total No. of people living with HIV 25,472
New adult HIV infections annually 1,193
New child HIV infection annually 65
4 National Strategic Plan for Tuberculosis, Leprosy and Lung Disease (2015-2018) 5 Kenya HIV County Profiles, NACC 2014
5 2.2.2 Key Drivers of HIV in the county • Sexual and Gender Based Violence (SGBV) • Ignorance and lack of information The following were identified as the key drivers of the epidemic: • Poverty:-manifests itself in other socio 2.2.3 Tuberculosis profile economic outcomes such as poor nutrition and County TB key indicators6 lack of access to basic services. The County has: • Economic activities (Truckers, migrant workers • Mid Case Notification Rate (CNR) (175-250/ in the Standard Gauge Railway (SGR) and 100,000) proposed Konza Technocity, DWA Sisal Estate; Mobile populations trading on fruits and • High poverty prevalence (> 45%) vegetables and sand harvesting; Rural urban • >40% of TB patients with Body Mass Index migration in search of jobs, Boda Boda riders (BMI) < 18 • Key population – MSM, sex workers and PWID • High HIV prevalence in general population along the Mombasa–Nairobi highway and (>5%) urban centres • Low community case notification • Stigma and Discrimination negatively (< 9% of total) influences access to services • Low pediatric case notification (<8% of total) • Intergenerational sex Table 2.2: Trend of County TB Outcomes • Alcohol and substance Abuse – Alcohol TSR Cure Lost To Failure Deaths Transfer abuse is an important co-factor in the sexual rate Follow- Out transmission of HIV and risk of TB disease. up
Cigarette smoking is linked to increased TB 2012 90% 85% 2% 1% 4% 2% disease. Drug possession, use, selling and 2013 91% 87% 3% 1% 4% 2% trafficking is illegal, causing drug users to 2014 92% 90% 2% 1% 5% 1%
remain a hidden population. Source: TIBU 2015
County TB case finding County TB case detection is at 82%. There’s need for concerted efforts to improve case finding in all sub-counties.
Table 2.3 TB Outcomes Case Findings
NEW PREVIOUSLY TREATED
SUB Bacteriologically Clinically Bacteriologically Clinically COUNTY confirmed Diagnosed confirmed Diagnosed
2013 2014 2015 2013 2014 2015 2013 2014 2015 2013 2014 2015 Kilome 93 84 78 95 61 54 12 16 15 13 16 15 Makueni 159 124 205 211 144 192 24 15 24 38 27 18 Kibwezi West 126 116 141 222 159 103 15 20 9 19 9 3 Kibwezi East 160 187 175 174 115 100 20 20 27 13 14 19 Kaiti 66 65 82 95 79 74 9 2 4 14 14 8 Mbooni 161 162 149 173 138 121 21 30 11 14 12 10 Source: TIBU 2014
6 National Strategic Plan for Tuberculosis, Leprosy and Lung Disease (2015-2018)
6 County TB Outcomes financial barriers stemming from the following areas: 2.2.4 Social determinants of TB transportation costs, fee-based diagnostic tests, and lack of nutritional and financial support during The role of poverty as a determinant of TB cannot the intensive phase of TB treatment. Malnutrition is be overlooked. According to the Makueni CIDP the known to negatively affect treatment outcomes. The County poverty rate stands at 64.3 per cent. In the NTLD programme estimated that 17% of notified TB Kenyan Demographic and Health Survey of 2009, cases were severely malnourished and a further 21% financial barriers were a primary cause of delay in moderately malnourished. seeking of health care. The review team identified
2.4: HIV and TB programmatic gaps and challenges
Table 2.4: Programmatic gaps and challenges
Programmatic areas of Major Challenge/ Gap intervention
eMTCT -Home deliveries ( use of TBA)
- Lack of Disclosure to spouses
-Non adherence to PMTCT prevention measures
-ART defaulter
-Low male involvement in eMTCT
-Delay in receiving DBS results
-Stigma and discrimination
Low partner testing
-Lack of knowledge ANC -Low uptake of ANC services( 64% coverage) DHIS 2015 HTS Low uptake of HTS services ( 21%- DHIS, 2015)
- Low partner testing
-Donor dependency
-Repeat testers
-Inadequate supply of RTKs
- Frequent changes in the HTS algorithm
-Missed opportunities
-Stigma and denial
-Attitude of Health care workers Adolescents and young people - No tools to capture adolescent data
- Non-adherence to support in schools
- Limited youth-friendly centres or resource centres in health facilities
- School drop out
- Family-based stigma and discrimination in OVCs
- No youth-friendly centre/ resource centres
- Knowledge gap in adolescent and young people programming
7 Programmatic areas of Major Challenge/ Gap intervention
Key populations, MSM, Sex Workers - Mainly donor supported and PWID) - No drop-in and rehabilitation centres
- Stigma and discrimination inhibiting Health seeking behaviours
- Lack of key population-sensitive health service points in health facilities
- Lack of size-estimate data
- Data tools do not disaggregate data to capture the Key Populations
- Inadequate psychosocial support groups
- Inadequate supply and accessibility to condoms and lubricants
- Inadequate sensitization of law enforcers on KPs and HIV programming
- Knowledge gap in KPs programming Gender Based Violence - Tools to capture data on GBV rarely utilized ( Post-Rape Care (PRC) form tool)
- PRC tool not harmonized with DHIS
- Lack of coordination between healthcare facilities and legal system
- Knowledge in GBV programming
- Lack of GBV reduction focal office ART - Non-adherence
- Long Turn-around Time ( TAT) for viral load results
- Pill Burden to HIV co-infections
- HIV testing entry points and enrollment into the Care and Treatment programme gaps
- Low pediatric ART coverage gap (45-%), adults coverage gap 37%
- Missed opportunities
- Inadequate linkage/ referral structures
- ART defaulters
- Self transfers
- Stigma and discrimination
- Multi-drug resistance (patients on second and third line treatment)
- Management of drug side effects (Pharma-covigilance utilization)
- Inadequate /stockouts of OIs Psychosocial support groups - Inadequate support during literacy classes ( snacks and transport)
- Non-involvement in programming
- Stigma and discrimination
- Poor linkage to community support systems Nutritional Support - Conditionality of donor supplies on nutritional feeds
- Erratic supply of government supplementary feeds (food by prescription) Faith healing and Herbalists - Treatment interruptions with herbal prescriptions and religious beliefs Behavior change and communication - Inadequate targeted IEC and BCC messages
- Access to IEC materials
- Low level of sensitization at grassroots
8 Programmatic areas of Major Challenge/ Gap intervention School Health programs Non-integration of HIV and TB in school health programmes
- Drug holiday in school setups
- Stigma and discrimination in school settings
- Overcrowded boarding schools Work place interventions - Inactive/non-existing workplace policies and implementation in County Departments and other government agencies
-Non-existing workplace policies and interventions in private sector (both formal and informal)
- Weak enforcement of occupational / Public health policies Human resources - Donor dependency in HR (E.g. ICAP supports 176 HIV HWS and 32 peer educators)
- High clinician-patient ratio
- Staff burn-outs
- Lack of skills and competence inventory HIV financing - Donor fatigue (Donors shifting priority areas)
- Lack of a HIV budget line in the health budget
- Non-disclosure of donor resource envelope Leadership and Governance Lack of political will and buy-in on some of the HIV activities, e.g. the KP interventions
- Poor parenting to the adolescents on sexual reproductive health
- Inadequate budgetary/ funding allocation towards TB, HIV/AIDS activities
- Poor accountability structures on HIV received funds at the periphery
- Weak structures to oversee the HIV/AIDS activities on the ground TB - Few diagnostic sites ( 76 sites)
- Faulty microscopy equipment
- Stockouts of commodities, i.e. Falcon tubes, sputum mugs, Xpertcartridges
- Knowledge gap in AFB/FM, GeneXpert
- Inadequate support supervision for sub county Medical laboratory Technologists
- Few geneXpert machines (the county has 3 GeneXpert TB machines in 3 subcounties)
- Inadequate nutritional support
- Poor health seeking behaviours (non-adherence, stigma and discrimination)
- Low screening of TB contacts
- Donor dependency GK Prison and Remand - Inmates sharing of ART and TB drugs
- Inmates not aware of their drug regimens
- Non-disclosure of inmates
- Inmates buying sputum from TB patients for exemption from prison duties and to get special diet (dispensing TB drugs to non TB patients)
- Denial of detainees’ conjugal rights leading to homosexuality Condoms - Lack of demand for female condoms
- Inadequate supply of condoms
- Inadequate promotion of condom use
- Lack of condom dispensers in strategic points
9 Programmatic areas of Major Challenge/ Gap intervention
Human rights and legal access - Inadequate information on legal rights of PLHIV
- Low level of awareness among the community on enforcement and protection of rights of PLHIV, OVC, PWD and Key Populations
- Limited access to HIV and AIDS tribunal by PLHIV and general population
- Few trained paralegals on HIV and AIDS issues
- Inadequate coverage of cash transfer to OVC households ( 34% coverage)
-Non-utilization of cash transfer funds to support OVCs by guardians M & E - Inadequate data capturing
- Poor feedback mechanisms
- Lack of aggregated tools for sub-populations such as adolescents, Isoniazide Preventive Therapy (IPT)
- Data quality issues in DHIS and COBPAR
- Inadequate M & E and support supervision to facilities and community-based implementers
- Non-harmonized reporting tools - one service reported in different registers
- Distortion of data
2.4 SWOT Analysis
Table 2.5: SWOT Analysis
Strengths Weaknesses Opportunities Threats • Presence of • High levels of stigma • Mobile HTS and PMTCT • Stigma towards usage of strong HIV services condoms due to cultural response • Illiteracy and religious barriers programmes and • BCC campaigns to promote structures in the • Irregular and inadequate funding of HIV and TB couple counseling • Food shortage County such as, activities CACCs; CSOs • HIV and TB prevention and • Droughts • Lack of resources to conduct regular mobile HTS Health facilities anti-stigma campaigns to hinterland areas • Epidemics and trained staff • Existence of the KASF • Few sub-ACUs implementing workplace policy on 2014/15-2018/19 • Rising poverty levels HIV and TB • Partner support • Training and capacity • Increase number of • Inadequate statistical data on the impact of HIV building programmes; OVCs and TB on the Human Resource in the County • Cash Transfer Support • Integration of HIV • High rate of drug and substance abuse Programme for OVCs and TB lessons in schools • HIV and AIDS hot spots along Mombasa road • Home and community care- based programmes • Stigma and discrimination • Integration of HIV • Establish youth-friendly and TB services • Donor Dependency of TB and HIV programming testing centres
• Poor health-seeking behaviours • Establish a data bank for PLWHIV and OVCs • Alcohol and substance abuse (increased use of miraa) • Scale up TB and HIV integration • Inadequate support of CSOs in HIV and TB response
10 Rationale, Chapter 3 Strategic Plan Development Process
3.1 Rationale HIV is the strongest risk factor for developing tuberculosis (TB) disease in those with latent or new The Kenya Constitution 2010 introduced two tiers Mycobacterium tuberculosis infection. The risk of of governance i.e. the National Government and developing TB is between 20 and 37 times greater the County Government. Health was amongst the in people living with HIV than among those who do devolved functions. Makueni County, being one of not have HIV infection7. TB is responsible for more the devolved governments, has therefore developed than a quarter of deaths among people living with a strategic plan to cater for the needs of her people. HIV8. The combined strategy for HIV and TB is a cost- The National Government is mandated with policy effective measure since HIV and TB are correlated in and guideline function to guide the counties in HIV programming and response strategies. and other health functions. The National AIDS Control Council (NACC), a national agency mandated to coordinate HIV response developed the Kenya AIDS Purpose of the plan Strategic Framework (KASF) 2014/15-2018/19; the • To guide policy formulation on HIV and TB National TB, Leprosy and Lung Disease Programme County response. developed the national strategic plan for TB, Leprosy and Lung Health (2015-2018), which guides counties • To inform HIV, AIDS and TB interventions in the to develop their specific HIV and TB strategic plans County. respectively. • To serve as the framework for resource In response to the dual epidemics of HIV and TB, mobilization and allocation. this strategic plan combines HIV and TB strategies. • To guide the implementation of the County multi-sectoral HIV, AIDS and TB response
7 WHO. Global Tuberculosis Control: A Short Update to the 2010 Report. December 2009. Geneva, Switzerland, World Health Organization, 2010 8 Getahun H et al. HIV Infection Associated Tuberculosis: The Epidemiology and the Response. Clinical Infectious Diseases, 2010
11 Figure 3.1: MCHTSP alignment and linkages
Aligned to:
• Kenya AIDS Strategic Framework 2014/15 – Informing: 2018/19 • County HIV and TB annual work plans • Kenya Vision 2030 • County Department HIV and TB Work • Constitution of Kenya 2010 Plans • Kenya Health Sector Strategic and Investiment MCHTSP • Faith Sector HIV and TB Work Plans Plan 2014-2018 • CSO HIV and TB Plans • Kenya HIV Revolution Roadmap • Makueni County Integrated Development Plan • Partners HIV and TB Work Plan 2013 • Makueni County Strategic Plan 2013 – 2018 • Makueni Annual Development Plan 2016 –2017
3.2 Guiding Principles • Integration of HIV and TB into general health programme: Integrated approach helps to • Equity: This is to ensure all services provided avoid the creation of vertical implementation of avoid exclusion and social disparities. care and treatment of HIV and TB. Integrated Investments are defined to ensure access to delivery reduces the unit cost of services. This services is equitable, irrespective of persons’ strategy emphasizes on integration of HIV and gender, age, colour, geographical location and TB into existing general health programme. social class. • Evidence-based programming: Informed • People-centredness: To ensure that HIV Result-based management on what works in and TB interventions are organized around HIV and TB prevention, care and treatment for people’s legitimate needs and expectations. effective and sustainable interventions. Interventions involving community participation are prioritized. 3.3 Strategic Plan Development • Participation: Involvement of different actors Process to attain the objectives of the plan. The process of developing the Makueni County • Multi-sectoral approach: This is based on the Strategic Plan began after dissemination of the recognition that health cannot be improved by Kenya AIDS Strategic Framework (KASF) 2014/15- interventions relating to health services alone, 2018/19 on November 28, 2014 at the national level with a focus of ‘Health in all Sectors’ required. and cascaded on December 1, 2014 into Makueni • Efficiency: To maximize the use of existing County. resources. The development of the MCHTSP started during the • Social accountability: To improve on the KASF dissemination and roll out for the County that public perception of HIV and TB services, was held on 14th – 15th October, 2015 at Lau Guest interventions that involve performance House, Machakos town. The stakeholders present reporting, public awareness, transparency and at the meeting consisted of County Government public participation in decision making on HIV representatives (CASCO, Sub-CASCOs, CACCs), Faith and TB-related matters are prioritized. Sector, Key Population representatives, Youth, PLHIV,
12 NEPHAK and Community-Based Organizations. The participants further agreed on a drafting team The participants were made aware of the KASF, for a strategic plan that would address the HIV and its proposed strategies and outcomes. The County TB response in the County. The team met for five days level dissemination further focused on enhanced in November 2015 and came up with a zero draft. The commitment, sustainability and ownership of the Zero Draft was subjected to the national review team County-specific HIV and TB response. for further analysis and input. A follow-up meeting During the meeting, participants reviewed and by the County Drafting Team was held in March, 2016 approved the Terms of Reference for the Committee to incorporate the inputs. A subsequent meeting for that was to oversee the development of the County both the County Drafting Team and the Technical Aids Strategic Plan. The participants also approved Review Team culminated the process in April 2016. the Committee members. The final copy of the MCHTSP was validated during a During the two-day workshop, participants were stakeholders meeting held on 21st – 22nd April, 2016 taken through the County HIV situation analysis and at Kusyombunguo Hotel, Wote Town. A Communiqué deliberated on the strategic directions for the County on amendments agreed upon was endorsed by the HIV strategic plan. The team also agreed on County CEC Health for adoption and circulation of the official HIV Committee TORs and membership. MCHTSP.
13 Vision, Mission, Objectives & Strategic Chapter 4 Directions
Mission Vision Provision of high quality HIV and TB A county free of prevention, new HIV and TB care and related infections, support services stigma and for all. related deaths
Objectives
The MCHTSP has four strategic objectives:
1 Reduce new HIV infections by 80% and reduce TB incidence by 5%: The primary aim is to use a combination of biomedical, behavioural, social and structural interventions to prevent new HIV and TB infections.
2 Reduce AIDS-related mortality by 30% and reduce mortality due to TB by 3%: The primary aim is to ensure access to quality treatment, care and support services for those infected with HIV and/or TB and to develop and implement interventions that focus on sustaining health and wellness.
3 Reduce HIV and TB-related stigma and discrimination by 50%: The aim is to protect the human rights of people living with HIV and TB, end stigma, discrimination, other human rights violations and gender inequality.
4 Increase domestic financing of the HIV and TB response to 50%: The aim is to reduce dependency on external HIV and TB funding and seek local alternatives. 14 4.4 County Strategic Directions 4.4.1 Strategic Direction 1: Reduce new HIV and TB infections
The County adopted eight Strategic Directions in One of the County health strategic interventions is to HIV and TB response as follows: invest in preventive health care. The County had an estimated 1,193 new adult and 65 children infections 1. Reduce new HIV and TB infections. in 2013. This strategic direction seeks to reduce 2. Improve health outcomes and wellness of TB new HIV infections by 80% thus reducing 1,258 new patients and people living with HIV. HIV infections to 252 by 2019. To reduce new HIV 3. Use a human rights-based approach to infections, the County will utilize the following key facilitate access to HIV and TB services. interventions: 4. Strengthen integration of health and community • Combination prevention approach. systems. • Targeted HIV prevention to priority populations. 5. Strengthen research and innovation to inform • Maximize efficiency in service delivery through the MCHTSP objectives integration. 6. Promote utilization of strategic information for • Leverage opportunities through creation of HIV and TB programming synergies with other sectors for HIV and TB 7. Increase domestic financing for a sustainable prevention. HIV and TB response.
8. Promote accountable leadership for delivery of (a) Combination prevention approach the MCHTSP results by all sectors and actors. Evidence-informed and human rights-based combination prevention recognizes the importance of biomedical, behavioural and structural interventions working together to achieve prevention and care outcomes9. A mixed approach addressing both immediate risks and underlying causes of vulnerability of priority populations (key and vulnerable populations) is both possible and necessary.
9 Catherine A. Hankins and Barbara O. de Zalduondo AIDS 2010, Core biomedical prevention interventions include condoms, VMMC, PMTCT/ART
15 COUNTY HIV, AIDS AND TB RESPONSE
BIOMEDICAL INTERVENTIONS
Include a mix of clinical and medical approaches, e.g HTS, ARVs Address deep-rooted social, Interventions that economic, political, address behaviours, e.g legal or environmental behaviour formation, issues, eg poverty, EBIs, drug adherence, stigma, gender condom use and intake inequality and of services marginalisation
BEHAVIOURAL STRUCTURAL INTERVENTIONS INTERVENTIONS
Figure 4.1: Combined approach interventions
16 Tuberculosis is known to have a strong association • Mobile/migrant populations: Labour-related with poverty10. Patients and households affected by movement to plantations, road/railway TB are likely to be caught in a ‘medical poverty trap’ construction across County is common. Social – a situation where treatment expenditures increase determinants arising from migration, such as as income levels decrease. living in cramped settlements, and income and There are many complex factors which influence food instability, increase the risk of TB. Access the twin HIV and TB epidemics and their prevalence to continuous care is constrained by many of 13 among populations. An effective response requires the social dimensions of migration . knowledge of the disease burden and main drivers • Prisoners: TB case notification rates in two of the HIV and TB epidemics in an area in order large prisons in Kenya - Meru and Embu - were to tailor appropriate interventions. There is a 941 and 4,714/100,000 respectively in 2012. correlation between HIV and TB as compromised These rates are 4-10 times higher than in the immunity in people living with HIV increases the risk surrounding population. It is estimated that of developing active TB, and TB can accelerate the similarly disproportionately high rates occur in course of HIV. The incidence of TB has increased other prison settings. parallel to the increase in the estimated prevalence • Boarding schools: The County has had case of HIV in the adult population. TB case-fatality rates notifications from overcrowded boarding are between 16% and 35% among people living with schools. HIV who are not on ART compared to between 4% • People Living with HIV: The incidence of TB is and 9% among people who are HIV-negative11. There eight times higher among PLHIV than in the is overwhelming evidence that early ART reduces TB rest of the population in Kenya.14 risk by 51%, AIDS-defining clinical events by 51%, and primarily clinical events by 27%12. • Contacts of TB patients: WHO Global recommendation in favour of screening of close The National Strategic Plan for Tuberculosis, contacts of active TB patients is based on five Leprosy and Lung Disease (2015 - 2018) recognizes cross-sectional studies showing that contact the following high-risk groups as hosting tracing contributed 2% – 19% of all cases. disproportionately high rates of TB and/or being under-served by health services: The MCHTSP • Chronic immuno-suppressive non- targets the following high-risk groups: communicable diseases: These include diabetes and cancers. • Urban slums: While the incidence of TB in slum areas throughout Kenya is not known, Pregnant women living with HIV are at risk for slums are considered a high-risk setting given TB, which can impact on maternal and perinatal the ease of transmission due to overcrowding outcomes. These could range from death of the and financial, geographical and social barriers mother and the newborn, to prematurity and low to care. birth weight of the newborn15. • Health care workers: In Kenyatta National The County will utilize a combination prevention Hospital, a study showed that the rate of TB approach for an effective response to TB. The among health care workers was three times following interventions combine behavioural, social, higher than in the surrounding community. structural and biomedical approaches.
10 WHO. Addressing Poverty in TB Control Guidelines (2005) 11 Mukadi YD, Maher D, Harries A (2001) Tuberculosis case fatality rates in high HIV prevalence populations in sub-Saharan Africa. AIDS 12 Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2012 13 International Organization for Migration, 2011: An Analysis of Migration Health in Kenya 14 Comparison of Trends in TB Incidence in Kenya, 1998 - 2012 15 Gupta A. et al. Postpartum tuberculosis incidence and mortality among HIV-infected women and their infants in Pune, India, 2002–2005. Clinical Infectious Diseases, 2007, 17 Intensified TB PPM, Workplace/ Case Finding Community Involvement
Infection Prevention Stigma Reduction and Control
County TB Response Isoniazid Preventive 2015/16 – 2018/19 Improved TB Data Therapy (IPT) M&E
- Integration Human Rights - Immunisation Approach
Initiation Socio-economic of ART empowerment
Figure 4.2: County TB response
18 (b) Targeted HIV prevention to priority • People Living with HIV and discordant couples populations • People in prisons and remand settings The County has had HTS campaigns which • OVC, PWD, widows and widowers significantly increased the total number of annual • Drug dependants and alcoholics tests conducted; however, such campaigns are conducted at significantly higher programmatic cost • Religious sects (E.g. Kavonokya sect) when compared with facility-based testing and with only a fraction of the yield. In addition, there is no Key and vulnerable populations face barriers to HIV evidence to show that the high-risk populations who testing and access to HIV care services due to age, are less likely to access HTS services at facilities were gender, marginalization and stigma. Community accessing the community-based HTS campaigns. settings provide an important entry point for case With this in mind, the County is shifting the finding of HIV+ at-risk individuals within high community-based testing model which focuses prevalence areas or groups. on general population access, to a more focused, targeted approach on priority populations (Key and (c) Maximize efficiency in service delivery vulnerable populations), and in which the highest through integration incidence and prevalence of HIV are documented. In line with KASF 2014/15-2018/19, the County will focus The MCHTSP identifies the following integrations as on the following priority populations: key in maximizing efficiency in service delivery. • TB and HIV: This plan prioritizes high impact (i) Key Populations (KP) interventions for TB and HIV integration with an emphasis on gaining efficiency from aligning The KP is populations with higher risk behaviours and programme management and consistent are at increased risk of HIV. collaboration and coordination of TB and HIV services through joint planning, budgeting, They include: implementation, supervision, monitoring and feedback. • Men who have Sex with Men ( MSM), • Family Planning and HIV: Rapid population • People who Inject drugs ( PWID) and growth is a threat to all health and development • Sex Workers (SWs), both male and female. goals in the County. Family Planning (FP) is the second prong of PMTCT; widely accessible (ii) Vulnerable population and consistently available FP services through multiple points of contact with patients and These are populations whose social contexts increase clients are critical components to controlling their vulnerability to HIV. They include: the HIV epidemic. • Adolescents and young people • Integration of HIV and TB diagnosis and care • Truckers and migrant populations ( SGR workers, in all service points: To minimize on missed workers in DWA Rea Vipingo Plantation) opportunities, this plan seeks to integrate HIV • Men, children and pregnant women living with testing and TB screening care and treatment to HIV all the facility entry points.
19 (c) Leverage opportunities through creation • Education sector of synergies with other sectors for HIV • Faith sector and TB prevention • Media The county will leverage on the following key sectors • Workplace settings to reduce new HIV infection: • Trade industry, tourism and cooperatives • GK prisons and remand centres • Road, transport and infrastructure
Table 4. 1: Interventions utilizing combination approach in targeted populations
MCHTSP Key Activity/ Sub Activity/Intervention Target Geographic Responsi- Result Intervention Population areas by bility on area county/ Sub county Biomedical Behavioural Structural
New HIV HIV prevention -Offer age -Increase access - Implement Adolescents All sub- All health infections targeting appropriate to sexual and cash transfer and young counties facilities reduced adolescent contraceptives, reproductive programmes people CSOs by 80% and young condoms, health services to keep girls Partners people microbicides - Offer peer-to- and boys in CASCOs -Establish youth- peer outreaches in school and friendly clinic school and out of social protection Social services school. for vulnerable development -Home-based - Implement families HTS during Evidence-based - Stigma Children school holidays Interventions( reduction department - Parents follow EBIs) campaigns up as index - Conduct life skill - Economic clients for testing trainings empowerment adolescents - Send messages through micro- -Implement intended financing for APOC to reduce youth out of intergenerational school sex - Review - Mass campaigns requirement of to motivate those parental consent testing HIV- for HIV testing negative to adopt - GBV reduction risk reduction programme behaviour and stay - Develop data negative. collection tools - Enhance to capture abstinence and adolescents and behaviour- young people change messages
20 Interventions utilizing combination approach in targeted populations
MCHTSP Key Activity/ Sub Activity/Intervention Target Geographic Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
New HIV infections HIV prevention - Carry targeted - Mass campaigns - Stigma General All sub- All health reduced targeting community to increase uptake reduction population counties facilities by 80% general outreaches of HTS campaigns population - Scale up PITC - Promote post- - Implement CSOs services to test HIV clubs GBV elimination periphery health - Promote safe sex programmes Partners facilities practices - Promote proper and consistent condom use
HIV prevention - Carry - Promote condom - Stigma Truckers Along the CEC Health targeting out mobile use campaigns reduction - (SGR transport truckers and outreaches - Install condom campaigns construction corridor CSOs construction - Moonlight HTS dispensers in - Implement workers) Partners workers - Establish strategic points GBV elimination SGR camps wellness centres programmes CHMT along the transport corridor - Offer HTS in all SGR camps
PLHIV and PLHIV and - Assist in partner - Initiate PLHIV and All sub- CHMT discordant discordant disclosure for linkages discordant counties couples couples PLHIV between human couples CSOs - Implement - Motivate HIV- rights abuses Networks of prevention with negative partner to identified in PLHIV positives (PWP) stay negative health facilities package - Engage peer with the legal Partners - Offer family educators to scale system planning services up family testing - Create - Offer HTS to for PLHIV awareness on partners and - Promote proper the HIV tribunal families of all HI- and consistent use services positive clients of condoms - Decentralize through intensive - Establish and the HIV tribunal contact tracing strengthen -Implement and Community- psychosocial GBV reduction Based HTS support groups for strategies (CBHTS) discordant couples - Offer HTS to partners and families of all HIV-positive clients
21 Interventions utilizing combination approach in targeted populations
MCHTSP Key Activity/ Sub Activity/Intervention Target Geographic Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
New HIV Prevention - Scale up HTS - Develop Raise awareness - HCWs All sub- All health infections targeting among PLWD by appropriate of people with counties facilities reduced People With disability category IEC materials disabilities to by 80% Disability - Increase access customized to enable them to PWD Partners (PWD) to ART and other each specific claim for their HIV services category rights CSOs -Train HCWs on - Sensitization - Implement sign language to campaigns disability- Community enhance service intended to conducive gate- provision reduce stigma and infrastructures keepers - Integrate HIV discrimination in in health sensitization the community facilities Faith Sector during medical -Advocate Media, assessments for condom packaging and County ART labels with Social Braille Services
Prevention - Offer targeted - Establish - Lobby for Key All sub- All health targeting Key HTS support groups 100% condom Populations counties facilities Populations - Scale up STI - Mass campaigns use policy in the (MSM, sex (MSM, sex management to increase service County workers and CSOs workers and in all health uptake PWID) PWID) facilities - Targeted Partners, - Offer PEP messaging and PrEP as - Implement CEC - the national alcohol and Health guidelines substance - Carry out abuse reduction Chair - moonlight HTS at programmes Health hot spots - Targeted Committee - Train HCWs and distribution of law enforcers condoms and on HIV-sensitive lubricants programming
22 Interventions utilizing combination approach in targeted populations
MCHTSP Key Activity/ Sub Activity/Intervention Target Geographic Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
New HIV PMTCT - Scale up family Establish and - Involve Pregnant All sub- All health infections planning to strengthen communities women counties facilities reduced prevent unwanted support groups for to challenge Children by 80% pregnancies pregnant women gender norms CSOs - Provide care, -Advocate for that affect the New TB treatment and pregnant mother health of women Partners infections support for to attend ANC and children reduced mothers with HIV clinics and deliver - Address home- by 5% and their children in health facilities. births through - Ensure all -Utilize mentor engagement children, mothers and education pregnant and to support of Traditional lactating women HIV-positive Birth Attendants are initiated pregnant women (TBAs). on ART as and pregnant - Encourage per national adolescents TBAs to escort guidelines - Promote and mother to health - Support partner scale up exclusive facilities for disclosure breastfeeding deliveries - Implement - Promote male - Promote regular engagement in child rights and community child HIV testing protection outreaches in far- and prevention - Lobby for to-reach areas - Promote ART incentives for - Strengthening adherence by use mentor mothers Clinical HTS adherence -Renaming of Mentoring counselors and MCH to Family to improve mentor mothers. Centres provider skills - Step up for managing community pediatric patients awareness at all health campaigns facilities. to improve - Screen all awareness, pregnant mothers linkage to and for TB retention in - Offer IPT to all care through eligible pregnant community mothers infected structures with HIV found not to have active TB - Integration of HIV services for the whole family in the MCH and PMTCT clinic - Implement PMTCT national guidelines
23 Interventions utilizing combination approach in targeted populations
MCHTSP Key Activity/ Sub Activity/Intervention Target Geographic Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
New HIV Scale up - Distribution Promote Strengthen General All sub KEMSA, infections use of male of condoms consistent and the supply population counties reduced and female as lubricants proper condom management County by 80% condoms to targeted use and disposal chain KPs procurement populations - Male and - Purchase unit - Increase access female condom penile and Adolescents to both male and demonstrations vaginal models and young Health female condoms - Create - Provide people facilities awareness on condom the importance dispensers CSOs of condom use in strategic among religious positions Partners leaders, herbalists and community gate keepers
Early infant - Conduct PCR - Community - Enhance DBS Infants All sub KEMRI diagnosis DBS at six weeks sensitization for transportation counties (EID) for all exposed uptake of service to national Health infants reference facilities - Integrate EID laboratory in immunization and feedback CSOs centres of results to facilities - Procure PCR machine - Decentralize KEMRI service to the County
24 Table 4.2: Interventions to maximize efficiency in service delivery through integration
MCHTSP Key Activity/ Sub Activity/Intervention Target Geographic Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
New HIV infections TB/HIV - Implement TB/ - Sensitize the - Strengthen General All sub– All health reduced integration HIV collaborative community of critical enablers population counties facilities by 80% activities availability of TB/ i.e. nutritional - Integrate TB HIV integrated support and CASCO New TB services in the services other social infections already existing protection CTLC reduced HIV services by 5% for mobile Partners, and migrant population CSOs - Integrate TB in already existing HIV service points and improve uptake of interventions for the co- infected
TB/HIV in - Offer screening - Strengthen Diabetic All sub- All health other service for TB among referral networks clients counties facilities delivery points all patients with to bring care chronic immuno- closer to patients General CASCO suppressive - Community population NCDs engagement in CTLC - Screen TB defaulter tracing patients for Partners, diabetes - Integrate TB CSOs and HIV screening and treatment in all service delivery points -Scale up IMCI in all facilities
25 Table 4.3: Interventions to leverage on other sectors to reduce new HIV and TB infections
MCHTSP Key Activity/ Sub Activity/Intervention Target Geographic Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
Reduced GK Prison - - Offer frequent Risk reduction - Review of Inmates Makueni GK Prison new HIV Makueni and and regular HTS counseling for HIV prison policy on prison, and admini- infection Remand set and TB screening negative testers HIV prevention to Prison staff remands stration, by 80% up - Establish prison - Establish include condom dispensaries psychosocial use, PrEP, safe Police - Train Prison support injecting needles admini- warders on ART/ mechanisms and conjugal stration TB management - ART adherence visits - HIV/TB session in prisons CEC - education for and remand Health inmates and staff - Provide IPT to CASCO, all prisoners - Increased CTLC access to appropriate HIV prevention, treatment, care and support services in prison settings including condom and lubricant distribution - Offer STI screening and treatment - Offer TB screening and appropriate treatment
Workplace - Offer HTS at - Promotion and - Enforce HIV/ Workplace All sub- Employers workplaces social marketing TB stigma and settings counties - Offer self- of condoms in discrimination County testing as per hotspots (hotels, policy. Establish County Public the national lodges and bars) peer educators Department Service guidelines - Implementation for HIV and TB at Boards of a minimum the workplace package of - Mainstream HIV services in HIV prevention the workplace activities in (sensitization, workplaces in all BCC, HTS, the sectors referral to clinical - Support HIV services, reduction prevention as a of stigma and Cooperate Social discrimination) Responsibility (CSR)
26 Interventions to leverage on other sectors to reduce new HIV and TB infections
MCHTSP Key Activity/ Sub Activity/Intervention Target Geographic Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
New HIV infections Education - Targeted HTS - Improve access - Ensure girls Students All schools MoEsT reduced Sector outreaches to accurate and boys stay in and colleges by 80% in schools, information on schools through Teachers and CEC - Technical training sexuality through social security support staff Education New TB institutes ( TTIs) introduction of programmes, infections and universities age-appropriate conditional cash CEC - reduced - Screening of comprehensive transfers and Health by 5% TB in boarding sexuality sanitary towels schools education in for girls Partners, and tertiary school curriculum - Address stigma institutions - Sensitization on reduction in CSOs - Provide IPT TB IPC activities in schools to contacts of schools - Implement CPHO smear-positive education policy, TB cases guidelines and teacher training that includes age-appropriate lessons on HIV, sexual reproductive health and rights - Enforce public health regulations in schools and tertiary institutions
Road, -Targeted - Promotion of - Develop Matatu drivers Transport CEC - transport and HTS and STI consistent and capacity through corridor Transport, infrastructure screening to proper condom cross-county Turnboys Standard Gauge use. collaboration Matatu CEC - Railway (SGR) - Establish and coordination Bodaboda terminals Health construction psychosocial of HIV along riders workers, support groups transport SGR camps Partners bodaboda riders, for HIV-positive corridor SGR matatu drivers workers construction CSOs and turn boys - Train peer workers - Establish educators to offer wellness centres peer-to-peer along the SGR sessions. and transport - Distribute corridors targeted IEC messages - Use public transport systems for prevention messages, condom and lubricants distribution targeting the general and Key Populations
27 Interventions to leverage on other sectors to reduce new HIV and TB infections
MCHTSP Key Activity/ Sub Activity/Intervention Target Geographic Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
New HIV Trade - Offer moonlight - Require HIV - Install condom General All hotels, CEC Health infections Tourism and HTS services prevention dispensers in population, KP lodges and reduced Cooperatives messages and Bars and lodges bars in all sub Partners by 80% industries services in hotels, counties bars and lodgings Hotel New TB - Condom and owners infections lubricants reduced distribution in by 5% lodges and bars - Targeted IEC materials Faith Sector Offer HIV and - Conduct and - Develop Religious All sub- Faith sector TB prevention adapt stigma-free curriculum for leaders counties represen- services in Faith HIV prevention training religious tatives based hospitals campaigns leaders on HIV Religious - Establish and TB centres -Hold workshops networks for with religious religious leaders leaders to living with HIV address the networkers notion of faith - Utilize youth healing as a groups for HIV and barrier to HIV TB prevention treatment and - Faith sector- adherence led/ initiated HTS campaigns Media - Hold joint media - Strengthening General All sub- County sharing forums on and provision Population, counties Public HIV, TB, GBV and of specific KP, men, Service stigma reduction support to media pregnant Board - Develop and associations mothers, initiate consistent of PLHIV, adolescents Department broadcast adolescents and and young of Labour programmes on young people people and HIV and AIDS for Meaningful ICT through the local Involvement of FM/TV stations PLHIV (MIPA) Local media - Develop age- houses appropriate messages as pamphlets in newspapers - Create new and strengthen existing coalitions of media organizations on specific themes of HIV prevention - Promote health service utilization including comprehensive HIV services - Documentaries on success stories, best practices and prevention messages
28 Table 4.4: Intervention to reduce new TB infections
MCHTSP Key Activity/ Sub Activity/Intervention Target Geographic Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
New TB Infection - Implement IPC - Carry out - Address HCWS, TB All sub- CTLC, infections Prevention in all County TB awareness social economic index clients counties reduced and Control Government and and screening barriers to CHMT by 5% (IPC) in privates facilities campaigns in prevention, health facility - Conduct annual school, colleges treatment CSOs settings screening of HCWs and prisons to initiation and - Accelerate intensify detection treatment Partners the operationa- of new cases completion lization of - Capacity build CASCO infection control HCWS on personal plans, starting preventive County with high-volume measures laboratory facilities - Implement the office - Integrate components of IPC TB Infection, (Administrative, Prevention and personal and Control (IPC) into environmental the general IPC measures) committees at facilities - Enhance TB IPC in diagnostic facilities (Provide bio-safety hoods, ventilators and N95 masks) - Intensify sputum transport to Central Reference laboratories and regional DR-TB gene-expert centres - Periodic screening for TB and HIV tests for HCWs - Carry out baseline risk/ need assessment in health facilities for IPC - Immunize all children as per national guidelines Intervention to reduce new TB infections
MCHTSP Key Activity/ Sub Activity/Intervention Target Geographic Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
New TB IPC in work Carry out -Develop and -Leverage on Work place All sub County PHIO infections places screening of implement TB other ministries settings counties reduced households and TB/HIV work e.g. housing, to CTLC by 5% contacts of place policies to embed IPC in children index TB promote infection planning policies Partners cases control - Enforce occupational Employers -Intensify early and public case finding health policies through structured in workplace contact tracing settings in facility and community settings. - Community sensitization on IPC in public transport vehicles
IPC in urban Intensify -Expand the - Expand - Urban slums All urban CTLC slums community availability of eligibility of and townships slums engagement and diagnostic sites social protect Partners outreach and referral programs to networks, include TB Community including sputum patients pharmacies collection points -Increase the to bring services engagement of CSOs closer to patients non-government providers already present in the slums or reaching slum dwellers
IPT children - Offer IPT as -Strengthen - Children and All sub CTLC and PLHIV per national adherence of PLHIV counties guidelines TB patients to Partners -Trace and screen treatment TB contacts - Offer supportive Community -Offer IPT to all adherence to INH child exposed to Prophylaxis Pharmacies smear positive -Scale up IPT with CSOs focus to reach all eligible PLHIV and children exposed to PTB+ - Harmonize clinic appointments for INH Review and routine HIV Care - Provide reporting tools - Ensure availability of Isoniazid
30 4.4.2 Strategic Direction 2: Improve • Ensuring that 90% of all people receiving anti- Health Outcomes and Wellness of TB retroviral therapy achieve viral suppression. patients and People Living with HIV • Increasing case notification of new TB infections to 85%.
The County has an estimated 22, 100 adults and 3, 372 • Ensuring treatment success of at least 95% Children Living with HIV16. There were 644 clinically- among all Drug Susceptible (DS) forms of TB. diagnosed and 830 bacteriologically-confirmed new TB cases in 2015. The TB/HIV co-infection was 28% as a) Ensuring that 90% of all people living at end of 2015, with a higher rate of mortality among with HIV are diagnosed and linked to care HIV-positive clients (17% among the co-infected and HIV testing is the gateway to accessing HIV treatment 6% in HIV negative)17. and care and a successful public health response to HIV requires robust HTS services. The County This strategic direction aims to: will re-focus its HTS programme to meet the goal of having 90% of PLHIV know their status by 2019. • Reduce morbidity and mortality resulting from With increasing HTS and ART coverage, finding the HIV and TB. remaining undiagnosed PLHIV becomes increasingly • Ensure that people living with HIV and TB challenging. Following the law of diminishing remain within the health care system and returns, the HTS programme projections in this adhere to their treatment through universal plan are based on the assumption that the number access to affordable and good quality diagnosis, of tests required will need to increase dramatically treatment and care. towards the end of the 4-year period in order to • Ensure that all services are responsive to the identify sufficient numbers of previously undiagnosed needs of people living with HIV and TB patients PLHIV to sustain the targeted ART scale-up. HTS will by integrating TB and HIV services within the be delivered through a strategic mix of facility and chronic-care system (to deliver longterm outreach-based models to cover the County gap of care), expanding clinic operating hours and 7,730 PLHIV (34% gap) 18who do not know their Status decentralizing HIV and TB care to community as at December, 2015, including linking them to care and dispensary levels. and treatment.
The focus of this Strategic Direction is to put the b) Ensuring that 90% of all people County on the path to achieving, by 2019, the TB and diagnosed with HIV are started and HIV treatment targets of: retained on anti-retroviral therapy • Ensuring that 90% of all people living with HIV Patients may be lost at various stages in the are diagnosed and linked to care. continuum of care. Early identification of PLHIV and their prompt enrollment in care would support • Ensuring that 90% of all people diagnosed with the 90-90-90 UNAIDS goal and maximize the HIV infection are initiated on anti-retroviral effectiveness of the existing programme strategies therapy and retained in care. to virtually eliminate progression to AIDS, premature
16 Kenya HIV County Profile 2014 17 TIBU 2015 18 NASCOP ACT Dash Board 2015
31 death and HIV transmission. Early ART has by far d) Increase case notification of new TB the most substantial effect on HIV incidence among cases to 85% of the previous year 19 all scientifically-tested interventions . The County Makueni County has a case notification rate of strives to meet the pediatric and adult ART gap of 31 <175/100,000. Case notification rates are loosely, 20 per cent translating to 6,359 PLHIV . yet inversely-related to prevalence of poverty; suggesting missing cases among the poor22. The c) Ensuring that 90% of all people receiving County has prioritized to put in measures to identify anti-retroviral therapy achieve viral and treat all TB cases, and to find the missing cases. suppression The final goal of ART is to ensure that those infected e) Ensuring treatment success rate of at with HIV attain undetectable levels of virus in least 95% among all drug-susceptible their bodies. A suppressed viral load is critical in forms of TB controlling the harmful effects of HIV infection on Treatment outcomes in TB patients may be people’s health and also reduces the risk of infecting influenced by various patient and health system others including sexual partners and children. The factors. The County will intensify efforts to mitigate County Viral suppression gap for adults and children these by enhancing access to health education on 21 is 11,054 (59%) PLHIV . TB, improved services that enhance retention, and strengthening referral networks to improve access to diagnostic treatment services.
19 UNAIDS. Ambitious treatment targets: writing the final chapter of the AIDS epidemic. In: UNAIDS, ed. Geneva: UNAIDS, 2014. 20 NASCOP ACT Dash Board 2015 21 NASCOP ACT Dash Board 2015 22 National Strategic Plan for Tuberculosis, Leprosy and Lung Disease (2015-2018)
32 Table 4.5: Interventions to improve health outcomes and wellness of TB patients and PLHIV
MCHTSP Key Activity/ Sub-activity/Interventions Target Geographical Responsi- Result Intervention Population areas by bility on area county/ Sub county Biomedical Behavioural Structural
90% of HTS for - Home-based - Integrate HIV - Education Guardians All sub counties, Health all PLHIV adolescents HTS during school care in youth- subsidy Adolescents schools, Facilities diagnosed and young holidays friendly sexual programmes to and young universities, and linked people and and reproductive keep children in people TTIs and MoE to care linkage to care - Parents follow health services school colleges up as index CHMT clients for testing - Behavior - Adolescences adolescents formation and youth- CASCO/ interventions friendly centres SCASCO - Same day enrollment for - Utilise CHVs - Update school CSOs HIV-positive to escort newly- HIV Curriculum adolescent and diagnosed Imple- young people HIV clients for - Incorporate menting enrollment HIV messages partners, - Scale up IPC in in school health all facilities - Intensify programmes KEMSA follow up of new diagnosed clients - Use social media to encourage the youth to seek HTS
HTS –KP and -Intensify -Implement -Stigma KP All sub counties Health linkages targeted HTS snow balling to reduction General facilities - Scale up STI reach KP campaigns population screening and - Train peer - Establishment HMT management educators in of more -Offer moonlight conducting psychosocial CASCO HTS along the accompanied support groups highway referrals to CSOs healthcare facilities Partners - Provide key messages to KP
33 Interventions to improve health outcomes and wellness of TB patients and PLHIV
MCHTSP Key Activity/ Sub-activity/Interventions Target Geographical Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
90% of HTS-Men, -Implement full - Involve CHVs -Implement Pregnant All sub counties Health all PLHIV Children and package of eMTCT and mentor male friendly women, facilities, diagnosed pregnant within ANC mothers in services Children, and linked women, and -Targeted testing referring and - Challenge CHMT to care linkages in all entry points follow up on ANC cultural (ANC, Maternity and postnatal practices that CASCO, and Postnatal mothers keep men from clinic) - Sensitise up taking SRH Partners -Increase access communities for services to DNA/PCR update of HTS CSOs testing for infants services in PMTCT - Utilise CHVs Community -PITC for children to escort new gate at points of diagnosed keepers, care i.e. OPD, HIV clients for paediatric wards, enrollment Faith sector MCH, and other -Follow up of clinics. new diagnosed -Parent follow up clients as index clients for children testing -Offer HTS during immunization campaigns with parental consent
HTS General -Provide for - Scale-up facility - Stigma General All sub counties Health population HTS counselor and community reduction population Facilities, and linkages supervision and linkages with campaigns CHMT, mentorship. inter- and intra- CASCO, - Scale up facility referral - One stop-shop partners, prevention and linkages. in all health CSOs interventions Sensitise facilities for TB, OIs communities for and other co- update of HTS morbidities, water services. and sanitation -Targeted HTS related diseases, campaigns vaccinations for preventable -Public diseases (cervical education on cancer, hepatitis, HTS pneumococcal) - Utilize CHVs --Targeted HTS in to escort new all inpatient wards diagnosed - Same day HIV clients for enrolment for HIV enrollment positive clients ( -Follow up of test and Treat) new diagnosed clients HTS targeting -Offer HTS and -Stigma Townships, SGR camps- Health Migrant TB screening reduction DWA sisal Kilome, Kibwezi Facilities, workers and in SGR camps campaigns plantation E & W CHMT, townships/ and low Income CASCO, informal settlements areas partners, settlements CSOs
34 Interventions to improve health outcomes and wellness of TB patients and PLHIV
MCHTSP Key Activity/ Sub-activity/Interventions Target Geographical Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
90% of ART – - Integrate - School-based - Review Care givers, All sub counties MoEST all PLHIV Adolescent HIV care and follow-up by teacher training started and and young treatment into HCWs curriculum to Adolescents TSC retained on people and youth-friendly - Provide care include updated and young ART linkages services givers with HIV information people CHMT - Implement APOC HIV education, - Reduce pill literacy and Partners burden through empowerment Fixed Dose - Adolescent CSOs Combination support groups (FDCs) linked up with Faith - Increase ART health facilities Sector, Central sites - School-based - Set special treatment County dedicated clinic literacy Director of days programmes Education - Utilise - Utilize teacher/ technology school support including staff to provide social media support for for education, adherence to recruitment and ART in schools retention in care - Supportive - Introduce disclosure electronic appointment cards
ART–KP - Integrate ART -Reduce stigma -Address MSM All sub counties Health services in drop-in to increase socio cultural PWID Facilities, centres access to care barriers to drug FSW and CHMT, Sensitize and treatment adherences. their clients CASCO, HCWS on KP -Address partners, programming stigma and CSOs discrimination by health care providers. -Empower KP to negotiate for safer sex (safer sex negotiation skills)
35 Interventions to improve health outcomes and wellness of TB patients and PLHIV
MCHTSP Key Activity/ Sub-activity/Interventions Target Geographical Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
90% of ART General - Address HIV/TB - Offer patient -Hold stigma General All sub counties Health all PLHIV Population co-infections education on reduction and population facilities started and drug adherence discrimination retained on - Reduce pill campaigns CHMT ART burden through - Establish and Fixed Dose strengthen - Formulation CASCO, Combination existing and use of (FDCs) psychosocial standard Partners support groups operating - Increase ART formation procedure CSOs central sites (SOPs) - Strengthen - Develop an treatment identification partners (uddy system (unique system) identifier) to identify and track - Mass media patients across all campaigns to services increase uptake of ART services - Integration of services - Implement patient retention - Screen all strategies pre-ART clients (treatment for hepatits B, literacy CRAG, geneXpert sessions, peer for ART eligibility and psychosocial assessment support)
- Conduct CD 4 - Utilize Count RRI for all technology pre-ART clients including social media for education, recruitment and retention incare
36 Interventions to improve health outcomes and wellness of TB patients and PLHIV
MCHTSP Key Activity/ Sub-activity/Interventions Target Geographical Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
90% of ART - men, -Initiate ART - Offer family - Empower Men, All sub counties Health all PLHIV children and as per national psychosocial families Children and facilities started and pregnant guidelines support to initiate pregnant retained on women and sustain women CHMT ART - Supportive livelihoods disclosure CASCO - Implement - Offer ART standard Partners adherence operating counseling procedures CSOs
- Offer nutritional counseling, support
- Scale up the mother-infant pair models utilising community systems such as mentor mothers and csos to enhance retention in care as well as defaulter tracing
37 Interventions to improve health outcomes and wellness of TB patients and PLHIV
MCHTSP Key Activity/ Sub-activity/Interventions Target Geographical Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
90% of Conduct Viral - Carry out viral - Promote ART - Decentralize PLHIV All sub-counties Health all PLHIV Load load tests to newly adherence viral load tests to facilities on ART ART-initiated, through the County achieving after six months, adherence CHMT viral 12 months then counselors and - Lobby for suppre- annually other HCWs nutritional CASCO ssion’ support - Capacity - Strengthen Partners build HCWs on psychosocial interpretation of group meetings CSOs viral load results - Strengthen KEMRI - Revive Multi- defaulter tracing Displinary Team mechanisms (MDT) in patients management - Strengthen network systems - Capacity build for transporting laboratory samples and technologist in relaying reports sample collection, handling and - Involvement transportation of treatment supporters and - Scale up family members routine viral in HIV care and load monitoring treatment in children to monitor ART failure and adherence
- Line listing of all clients in pre-ART and ART registers to identify those eligible
38 Table 4.6: Intervention to improve health outcomes of people with TB
MCHTSP Key Activity/ Sub-activity/Interventions Target Geographical Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
TB Intensify TB - Build capacity - Expand - Address General All subcounties Health mortality Case finding of health workers commu- stigma and population facilities reduced by (ICF) and laboratory nication efforts discrimination 3% technicians to in communities associated with Boarding CHMT identify and to stimulate TB school diagnose TB care seeking - Lobby for settings CASCO behaviours inclusion of - Strengthen TB and HIV in Partners implementation - Strengthen County social and monitoring CHEWs, CHVs protection CSOs of systematic and CSOs in TB strategies TB screening at prevention and health facility, in- case finding patient wards and community levels, - Offer health with improved education documentation forums through of presumptive baraza and TB cases and media, national linkages to events including diagnostic and World TB Day care sites. - Carry out - Ensure the contact tracing of availability of all TB patients referral networks for sputum - Integrate samples and CBTBC in patient care Community Units and CSO - Intensify activities technical assistance - Establish and and supportive strengthen TB supervision expert support from Centres of groups Excellence or the NTLD Programme
- Enhance identification and linkages of TB and other Departments including OPD
- HTS in chest clinics
39 Intervention to improve health outcomes of people with TB
MCHTSP Key Activity/ Sub-activity/Interventions Target Geographical Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
TB ICF targeting - Implement TB -Enhance - Address Inmate and GK prisons- CTLC mortality Prisoners and infection controls infection control stigma and prison staff Makueni reduced by prison staff in Prisons as in prison and discrimination Prison 3% per national detention associated with admini- guidelines settings TB stration, - Lobby for - Carry out -Develop IEC inclusion of Partners screening upon materials for TB and HIV in entry to prisons prisoners and County social using P10 prison staff protection strategies -Introduce -Develop referral diagnostic and mechanisms for DOT capacity on prisoners who site are transferred or released -Introduce annual TB screening as part of routine/ periodic wellness examination for prison staff
ICF targeting -Integrate child - Community - Initiate social Children All facilities HCWs Paediatric TB TB services in engagement for support for OVCs of PTB+ (County, private MCH, PMCTC, contact tracing on TB treatment. guardians and mission) Partners OPD, pediatric , supervision outpatient clinics of DOT for -Carry out CSOs and pediatric TB patients awareness and inpatient wards and tracing TB screening in CHEWS clinics defaulters schools, colleges and orphanages CTLC -Utilize - Increase to intensify GeneXpert, chest community detection of new x-rays, and TST advocacy and cases. in diagnosis of awareness on pediatric TB. childhood TB. -Establish and -Capacity build equip chronic HCWs on child TB - Conduct active care clinic for case detection, contact tracing asthma and diagnosis and and screening for other chronic treatment 100% of patients lung conditions with DR-TB - Ensure uninterrupted supply of paediatric friendly DR_TB formulation for children
- Eliminate diagnostic fee for children
40 Intervention to improve health outcomes of people with TB
MCHTSP Key Activity/ Sub-activity/Interventions Target Geographical Responsi- Result Intervention Population areas by bility on area county/ Sub county
Biomedical Behavioural Structural
TB Workplace TB - Active screening -Training and -Establish and HCWS, Work place CTLC mortality interventions of workers for TB. support of peer implement work employees settings reduced by -IPC measures educators. place policy that HCWS 3 % in all Health care -Develop and protects TB/ settings disseminate HIV workers CPHO TB and HIV IEC from stigma and materials discrimination Employers -Implement and the fear/ occupational reality of loss of health safety income measures - Ensure mandatory inclusion of TB benefits within the health insurance package
TB treatment -Use mobile Establish Initiate TB Patients, TB Clinics HCWs and technology psychosocial sustainable TB and HIV Management platforms to send support groups livelihood and co infected CTLC SMS reminders e.g. TB clubs, TB food security patients for TB clinic ambassadors. imitative. CSOs attendance -Scale up -Lobby for Partners - Manage treatment policies to malnutrition in support strategy reduce direct Children with TB costs on TB -Strengthen diagnosis and - Offer TB defaulter tracing treatment treatment as by use of CHVs per the national -Offer DRTB guidelines -Offer nutritional patients support support for including food -Provide DOT by malnourished HCW for DRTB TB or TB and HIV patients -Provide drug resistance -Workplace surveillance to treatment as per national support for guidelines. patients on TB medications. - Offer ART to TB and HIV co infected patients as per national guidelines-
41 4.4.3 Strategic Direction 3: Strategies to address the HIV epidemic in the County are hampered by an environment where human Use a human rights-based approach to rights are not respected. For example, stigmatization facilitate access to HIV and TB services and discrimination against marginalized groups such as sex workers and MSM drive these populations Human rights, HIV and AIDS are inextricably linked. underground. This impedes efforts to reach them Lack of respect for human rights fuels the spread with prevention initiatives, thereby increasing their of HIV and exacerbates the impact of the epidemic vulnerability to HIV. Similarly, failure to provide access on children and families. At the same time, HIV to appropriate information about HIV, or treatment, undermines progress in the realization of human and care and support services further fuels the AIDS 23 rights. Stigma and discrimination are particularly epidemic. pronounced for socially excluded populations (e.g. The Constitution of Kenya 2010 in Article 27 recognizes Sex Workers, transgender people, Men who have that measures should be put in place to encourage Sex with Men or People Who Inject Drugs) and their affirmative action programmes and policies to families as well as adolescents at higher risk of HIV address past inequalities. Economic and social rights exposure. to all are also recognized in Article 43. These include Certain groups are more vulnerable to contracting the right to health care services, adequate housing, the HIV virus because they are unable to realize their and sanitation, adequate food of acceptable quality, civil, political, economic, social and cultural rights. clean and safe water and appropriate social security 24 Gender-Based Violence and gender inequality, for to vulnerable groups in the society. example, heighten the vulnerability of women and girls to HIV infection, particularly where access to The MCHTSP seeks to: education, age-appropriate HIV information as well as • Remove barriers to access of HIV and TB rights sexual and reproductive health services necessary to information and services prevent HIV infection are unavailable or inaccessible. Promoting the full realization of all human rights and • Improve County legal and policy environment for gender equality is therefore critical for preventing protection of the rights of priority populations the spread of HIV, mitigating the social and economic and TB patients impacts of the epidemic, and achieving an AIDS-free • Reduce and monitor human rights violations generation. including SGBV, IPV and stigma and discrimination
23 UNAIDS 2014 24 Kenya Constitution, 2010
42 Table 4.7: Interventions for using human rights-based approach to facilitate access to HIV and TB Services for PLHIV and TB patients
MCHTSP Key Activity/ Sub-activity/Interventions Target Geographical Responsibility Result Intervention Population areas by on area county/ Sub county
Stigma and Remove - Promote uptake of HIV pre and post-exposure Key All sub- CEC Health discrimination barriers to prophylaxis among survivors of sexual violence Populations counties reduced by access of HIV and priority population CASCO 50% and TB rights Survivors of information - Sensitize County assembly to enact laws that SGBV CSOs and services prohibit discrimination and against PLHIV/Key Partners Populations OVC Faith sector, - Train prisons personnel regarding HIV and TB Patients TB prevention, health care needs and human Media rights of detainees infected with or at risk of TB and HIV, and support access to HIV care County social and treatment services
- Conduct legal literacy (know your rights) campaigns to improve legal and human rights literacy among KPs, PLHIV and TB patients and priority populations.
- Train and sensitize HCWS to reduce stigmatizing attitudes in health care settings
- Integrate HIV information and encourage service uptake in religious teachings - Facilitate campaigns on reduction of stigma and discrimination, GBV, IPV and promote uptake of HIV services and TB prevention interventions
- Enroll OVCS, PLHIV and TB patients into social protection programmes
- Roll out sustainable Income Generating Activities (IGAs) to empower vulnerable populations
- Develop and disseminate ‘know your rights’ population-specific IEC materials
- Integrate HIV and TB in religious teachings
- Use of KP peer groups to enhance uptake of HTS and TB services
43 Interventions for using human rights-based approach to facilitate access to HIV and TB Services for PLHIV and TB patients
MCHTSP Key Activity/ Sub-activity/Interventions Target Geographical Responsibility Result Intervention Population areas by on area county/ Sub county
Stigma and Improve - Lobby for County enactment and Key All sub- Judiciary, discrimination county legal implementation of laws, regulations and Populations counties reduced by and policy policies that prohibit discrimination and and peer County Assembly 50% environment support access to HIV and TB prevention, care groups for protection and support CEC- Health of the rights PLHIV of priority - Provide legal services to those who face NGOs/CSOs populations human rights violations TB patients and TB HIV tribunal patients - Facilitate access to justice and redress in General cases of HIV-related discrimination or other population Partners legal matters
- Capacity building to civil society to promote access to justice.
- Hold County Government accountable to their constitutional and statutory obligations
-Implement the TB patient Treatment charter
- Decentralization of HIV/AIDS tribunal centre to County and sub-counties
- Empower communities to participate in proposed County Bills
- MIPA in policy formulation and planning including commemoration of World TB and AIDS day
- Enforce PLHIV rights
Reduce and - Develop tools to monitor incidents of rights Communities, All sub counties Human rights monitor violation, including discrimination, GBV and institutions human rights denial of health care services for KP, PLHIV Health violations and TB patients settings Employers including SGBV, IPV and - Sensitize communities/ populations on their Work place CEC - Health stigma and rights settings discrimination HIV tribunal - Invest in community programmes to change Partners harmful gender norms and stereo types CSOs - Introduce SGBV desks in health facilities and train health personnel on SGBV
- Lobby for a County legislation on SGBV
- Establish SGBV rescue centres 4.4.4 Strategic Direction 4: activities and interactions has never been more apparent. Communities have a key role to play in Strengthen integration of community identifying, promoting and facilitating service uptake and health systems among members of key and vulnerable populations. The County is cognizant of the need to strengthen Increasingly, specific tasks (such as HIV screening health systems through investing in diagnostic and adherence support) can be shifted away from capacities and balancing the health facilities in overburdened healthcare service providers to existence with adequate personnel. One of the community and home-based service delivery models County health flagship projects is to establish a which have been demonstrated to be effective. telemedicine centre at the County referral hospital Communities and civil society organizations play an and connected via media to other County hospitals. additional role in working to ensure key enablers Doctors will be able to attend to medical cases by are in place so that service delivery achieves guiding medical officers on making diagnosis and maximum impact. Therefore, strengthening social eventual prescription. The telemedicine centre will networks, CSOs and Community Strategy units will be complete with a medical app providing integrated have a positive impact on the ability of populations medical services25. including the key and vulnerable populations to The community is an under-utilized resource in engage in health care and effectively contribute to HIV and TB response in the County, and the need the achievement of MCHTSP. to more closely coordinate facility and community
Figure 4.3: Makueni County health and community systems integration model
Health System Strengthening Community System Strengthening - Skill match and adequate distribution of health - Build technical and workforce organizational capacity of CSOs and Community Health Units - Invest in diagnostics capacities Linkages and Integration - Support CSOs resource - Strengthen service delivery mobilization initiatives - Strengthen supply chain - Capacity-build communities management for HIV and TB, to identify and document local commodities, vaccines and knowledge, lessons learnt and technologies situational assessment of HIV - Establish a telemedicine and TB interventions centre
25 Makueni County Annual Development Plan 2016-17
45 Some sectors, for example the faith-based sector, In this regard, this plan seeks to achieve the following have an extensive network of institutions and • Provide a competent, motivated and adequately individuals in communities, from densely populated staffed health workforce at the County to towns to the most remote rural areas in Makueni. deliver HIV services integrated in the essential This network is coupled with infrastructure, e.g. health package. places of worship, halls, schools and hospitals, • Strengthen health and community service which can be used to enhance existing programmes delivery system. and create new programmes and services; and to act as points of service delivery, information centres and • Improve supply chain management for HIV points of referral to services. commodities.
Table 4.8: Interventions to strengthen integration of community and health systems
MCHTSP Key Activity/ Sub-activity/Interventions Responsibility Result Intervention on area Strengthen Recruit and -On job training of all HIV service providers County Public Service Board health and retain competent, -Implement Continuous Medical education( CME) on TB, DR/ community motivated and TB and HIV CEC Health systems adequately staffed - Create incentives in terms of remuneration, promotions, health workforce Provision of study leaves and sponsorships to HCWs Partners - Implement staff recognition such as end of year awards for best performing HCW. - Recruit HCWs (HTS counselors, Laboratory technologies, Clinicians, social workers, nutritionists). - Train HCWS on HIV and TB collaborative, Paediatric TB, DRTB and PAL activities -Develop and implement a Health staff retention policy -Redistribution of HCWs to ensure availability of appropriated competent staff. -Build capacity of Public health workers in targeted intervention for sensitizing health workers to work with people living with HIV and TB patients. -Build capacity of the Laboratory Staff for HIV and TB screening. -Train laboratory HCWs on AFB microscopy, FM and GeneXpert -Train HCWS on APOC Ensure health workers have access to prevention and other HIV– and TB-related services, immunization against vaccine- preventable diseases, especially Hepatitis B. -Consider task shifting as a way of increasing the pool of knowledgeable HIV and TB-related service providers and more- to-less-specialized health workers. -Ensure package of HIV and TB prevention, treatment and care services to health workers and their families on a priority basis and should be tailored specifically to their needs. - Establish occupational health and safety procedures to reduce the risk of contracting HIV, TB, Hepatitis and other blood-borne diseases in health settings. -Address stress and burnout, prohibiting HIV, TB-related and other forms of discrimination
46 Interventions to strengthen integration of community and health systems
MCHTSP Key Activity/ Sub-activity/Interventions Responsibility Result Intervention on area
Strengthen Service delivery - Decentralize HIV comprehensive services to health centres CEC - Health health and and dispensaries community - Implement task shifting and mentorship programmes CHMT systems - Train Community Health workers on home and community- Based Care (HCBC) Partners - Establish and strengthen existing Community units as per the community strategy guidelines CSOs - Build the capacity of CSOs in HIV and TB interventions - Comply with and carry out all routine quality assurance and County Social Services quality control measures for HIV and TB - Establish a telemedicine centre -Enhance community care financing by: - Enhancing ability of CSOs to attract funding from diverse funding agencies through organisational development mentoring, - Proactively linking CSOs with funding agencies, - Supporting sustainable income generating activities by CSOs. - Allocate County budgets for CSOs interventions
Supply chain - Strengthen capacity of the County, sub-county and facilities KEMSA management to appropriately plan for, procure, store. And distribute and manage inventories of commodities CEC Health - Strengthen and link DHIS, TIBU and LMIS systems for better management of supplies CHMT -Timely distribution of HIV and TB commodities from County to sub-county level CHTC - Ensure quality of TB medicines and diagnostics in the County and sub-counties NTLD programme - Proper quantification and timely procurement of HIV and TB commodities from KEMSA by County NASCOP - Timely distribution of HIV and TB commodities ( OIs drugs, condoms, test kits, TB Drugs) from KEMSA to facilities - Establish commodity security committees at the County and sub-county levels - Build capacity of HIV and TB commodities management into exiting LMIS commodity management packages
47 4.4.5 Strategic Direction 5: Makueni county research gaps and challenges Strengthen research, innovation and The County faces the following research gaps and information management challenges: • Inadequate data on barriers to access to HIV HIV and TB research specific on implementation will and TB services. be strengthened as a critical component of HIV and TB strategic information to document the knowledge • Inadequate information on the existing sexual gap in terms of effectiveness of intervention and networks and HIV granulation in sub-counties/ implementation approaches so that the coverage is ward levels. improved. • Limited engagement and involvement of other The main goal of research on HIV and TB in Makueni sectors in HIV and TB response. County is to provide scientific evidence to guide and • Inadequate information on effectiveness of enhance the County’s response. Four main streams community capacities to address HIV and TB. of research are presented as the basis for generating • Inadequate information on cost effectiveness the knowledge needed to support the objectives of and efficiencies of HIV and TB programmes. the MCHTSP namely: • Frequently changing guidelines – not allowing • Surveillance and vital statistics for adequate implementation research. • Health systems and operations research • Research for innovation • Policy, social and public health research
County research priorities Table 4.9: County research priorities
Strategic Direction Research Priority
SD1: • Understanding drivers of epidemic by population and geography Reduce new HIV and TB infections • Map HIV sub-types and sexual networks • Identify barriers to testing and access to intervention services by populations SD2: • Barriers to initiation, linkage and adherence into care for TB and PLHIV Improve health outcomes and wellness of TB • Determine effective models for increasing adherence in different patients and people living with HIV populations • Correlation of nutritional status of TB patients and their treatment outcomes • Review of IPT efficacy in preventing new TB infections among PLHIV
SD3: • Establish determinants of access to justice for sub-populations Use a human right-based approach to facilitate access to HIV and TB services
SD4: • Determine suitable models of community systems to support delivery of Strengthen integration of health and community cost-effective HIV,TB and SRH responses systems
SD7: • Determine the most effective and suitable model of domestic. Increase domestic financing for a suitable HIV • Determine the factors that would facilitate ownership and accountability and TB response for HIV response. • Evaluate effectiveness of existing HIV coordinating mechanisms SD8: Promote accountable leadership for delivery of the results by all sectors and actors
48 In order to strengthen the County research, innovation and information agenda, this Plan proposes to: • Resource and implement County HIV research priorities • Increase evidence planning and programming
Table 4.10: Interventions to strengthen research, innovation and information management
MCHTSP Key Activity/ Sub-activity/Interventions Responsibility Result Intervention on area Strengthened Resource for Partner with universities and colleges to prioritise HIV CHMT County Research research. CEC Health Research, -Lobby for HIV research budget line in the HIV budget. Partners innovation and Academic institutions information management Build Capacity of Train HCWs including laboratory personnel on HIV and TB CEC Health HCWs on research research CHMT Enhance collaboration with local training institutions Partners establish a HIV and TB research coordinating unit Local training institutions Conduct operational research Develop a County research agenda on the basis of detailed knowledge of the burden of disease
Application of -Disseminate research finding to county stakeholders to CHMT research in policy makers Partners decision making -Establish a resource centre CEC Health
-Publication of research findings in pamphlets and postings in the county web page for wider dissemination
4.4.6 Strategic Direction 6: Promote utilization This plan will utilize data generated from the various of strategic information for HIV and TB sub-systems using HIS in five key areas: programming 1. Information generation – the different forms The County data sources are: of information and how they are collected and • Facility-based data/ information system - DHIS stored. • Community-Based interventions - COPBAR 2. Information validation – the process of and Community Strategy Reporting reviewing the information to improve its accuracy and representativeness. • School-Based Interventions - School Health Reports 3. Information analysis – the process of understanding what the information is saying. • Social protection - conditional cash transfers reports 4. Information dissemination – the process of sharing the emerging information from the • Workplace intervention - Work place reporting analysis with relevant stakeholders. system 5. Information utilization – the process of ensuring • TB response - TIBU information available is informing the decision • Commodity management - LMIS making process.
49 This Strategic Direction seeks to: routine and non-routine monitoring systems • Strengthen M & E capacity to track MCHTSP for quality HIV and TB data. performance. • Establish Multi-sectoral and integrated real- • Ensure harmonised, timely and comprehensive time HIV platform for HIV response updates
Table 4.11: Interventions to promote utilization of strategic information for HIV and TB programming
MCHTSP Result Key Activity/ Sub-activity/Interventions Responsibility Intervention on area Strategic Strengthen M/E - Conduct M&E capacity assessment and capacity development CEC - Health information in capacity to track needs programming the MCHTSP - Capacity building HCWs and community-based implementers CHMT utilised performance on M & E - Establish and strengthen functional multi-sectoral HIV M& E CTLC coordination structure and partnerships - Conduct periodic trainings and OJT on M&E identified gaps CHRIO - Provide the relevant data/M&E tools for health, community- based and workplace interventions CSOs - Orient the HCWS and CSOs on the use of the tools - Ensure regular monitoring and supervision- Equip all health Partners facilities with EMR systems and infrastructure - Establish County information resource centre - Lobby for sustainable financing of HIV M & E planned activities - Conduct quarterly Data Quality Audits ( DQA) - Improve TB surveillance data tools to capture child TB nutritional assessment data Harmonise routine - Harmonise the County and implementing partners reporting CEC - Health and non-routine tools monitoring systems - Develop comprehensive HIV M& E systems guideline, tools and CHMT for quality HIV data Standard Operating Procedures - Create linkages between data collection tools and database Partners - Strengthen HIV data management - Conduct periodic data quality audits NASCOP - Conduct M & E supervision - Honour national and County HIV reporting obligations NTLD programme - Introduce a register for presumptive TB and allow capturing of screening and referral results, and to enable treatment follow up NACC - Revise and update facility chalkboards to include comprehensive TB indicators CSOs - Integrate Community-based TB indicators in the TIBU and DHIS systems Partners Develop and disseminate TB data capturing tools for use by CSOs and CHEWS Include TB indicators in the situation room platform Establish Multi- - Establish and utilise County HIV Situation Room CEC - Health sectoral and - Create data demand and use of HIV and TB strategic integrated Real information in programming CHMT time HIV platform - Create and strengthen M & E information hub for response - Integrate TB indicators in the HIV Situation Room Partners updates
50 4.4.7: Strategic Direction 7: Increase domestic financing for sustainable HIV and TB response The County health department was allocated approximately 31% (Ksh1,872,556,029) of County budget in the Financial Year 2014/2015. Most of these funds were consumed by recurrent expenditure (83%) with 266,941,110 (17%) utilized for development. The 2015/16 Financial Year also saw no funds directly allocated for HIV and TB response. This calls for affirmative action aimed at increasing domestic financing for HIV and TB response from zero to 50% by the year 2019. The county government envisages an allocation of 3% of health budget to HIV and TB response in the 2016/17 Financial Year.
Table 4.12: County Health Budget Allocation Trend26
Financial Year Allocation Recurrent Expenditure Development Allocation for HIV and TB
2015/ 2016 2,128,759,687.39 1,599,941,627.54 528,818,059.85 Nil
2014/ 2015 1,872,556,029.27 1,605,614,919 266,941,110.02 Nil
2013/ 2014 1,458,575,274.94 1,216,136.770.94 242,438,504.00 Nil
Sustainable Financing of HIV and TB The national HIV and TB response continues to experience diminishing funding from the traditional development partners. In addition, the rebasing of the economy in year 2014 has implications for HIV and TB response. In the near future, the Country will not be able to procure HIV and TB commodities at a subsidized rate. This has translated to a trickling-down effect to county governments. While the MCHTSP is not a strategy of the health department, the majority of the directly attributable costs are incurred within the health sector. This calls for the County Government to explore innovative and sustainable alternative sources of funds. Research on expediting strategies on generation of funds must be commenced with speed.
The MCHTSP Seeks to: • Maximize efficiency of existing delivery options for increased value and results within existing resources. • Promote innovative and sustainable domestic HIV and TB financing options. • Align HIV and TB resources/ investments to MCHTSP priorities.
26 Makueni County Budget 2013/14, 2014/15 and 2015/16
51 Table 4.13: Interventions to increase domestic financing for sustainable HIV and TB response
MCHTSP Key Activity/ Sub-activity/Interventions Responsibility Result Intervention on area Increased Maximize efficiency - Implement on-job-training (OJT) models utilizing National HIV CEC Health domestic of existing delivery Integrated Training Curriculum (NHITC). This could reduce training CHMT financing for options for increased cost by up to 70% Partners sustainable HIV value and results - Rationalize HIV commodities distribution and reduce cost of CHTC and TB response within existing laboratory referrals resources - Implement NHITC in training of HCWs to reduce absenteeism in health facilities - Integration of HIV/RH/TB and MNCH services - Promote resource allocation that has the greatest impact on achieving the Strategy objectives - Map out development partners in the County (Location of operation and their interventions) to minimize duplication of efforts
Promote innovative - Lobby for clients to take up NHIF insurance CEC Health, and sustainable - Initiate Community-Based Health care Financing ( CBHF) CEC Finance domestic HIV and TB - Lobby for HIV trust fund financing options - Contribute 3% of the County health budget to HIV and TB CHMT intervention - Establish a HIV budget line in the Health allocation) Partners - Initiate Public Private Partnerships (PPP) for HIV and TB response - Appeal to philanthropists Chair health - Undertake charitable events, e.g. marathons, charity walk committee, - Establish a HIV lottery - Apportion interests from dormant funds (unclaimed assets) to CHTC HIV and TB response - Encourage organized informal sector contribution County treasury - Tax holiday for individuals and corporate in HIV and TB philanthropists - Float health bonds - County to encourage financing of HIV and Tb initiatives by legislating rebate on county taxes for traders
Align HIV resources/ - Track government allocations towards HIV response to the CEC Health, investments to different County Government departments MCHTSP priorities - Engage County assembly to consider HIV as an added parameter CHMT in resource allocation - Facilitate implementation of deliberate measures to unblock Partners the financial, human, infrastructural, institutional, and structural bottlenecks that impact absorptive capacity to financing HIV Chair health programmes Committee - Facilitate quantification of County resource needs - Implement a partnership accountability (MoU) to ensure CHTC alignment of resources to MCHTSP priorities - Facilitate planning by reporting contribution to MCHTSP annually
52 4.4.8: Strategic Direction 8: Promote that the County Governor submits the county accountable leadership for plans and policies to the county assembly for delivery of MCHTSP results by approval together with an annual report on the all sectors and actors implementation status27. Political will, vision and leadership are essential, especially at the highest level In Strategic Direction 8, the MCHTSP seeks to: of government. Such leadership should • Build and sustain high level political and recognize that practical steps must be taken technical commitment for strengthened County to allocate county resources to HIV and TB- ownership of the HIV and TB response. related priorities and to marshal institutions • Entrench good governance and strengthen and actors beyond the health sector. multi-sector and multi-partner accountability The County Government Act, 2012, requires for delivery of MCHTSP results. the County Executive Committee to design a • Establish and strengthen functional and performance management plan to evaluate competent HIV and TB co-ordination implementation of county policies by the mechanisms. county public service. It further requires
27 KASF 2014/15 – 2018/19
53 Table 4.14: Interventions to promote accountable leadership for delivery of MCHTSP results by all sectors and actors
MCHTSP Key Activity/ Sub-activity/Interventions Responsibility Result Intervention on area Accountable Build and sustain - Provide effective leadership and support for multi-sectoral CEC Health leadership and high level political HIV and TB response governance and technical - Lobby for high level political support and commitment to CSO commitment for county HIV and TB response strengthened - Give feedback and reports to county leadership on the CHMT county ownership progress of MCHTSP implementation of the HIV and TB - Lobby for equitable distribution and access to HIV and TB CHTC response services - Coordinate stakeholders in implementing MCHTSP Chair Health committee - Mobilize local communities to participate in HIV and TB response - Lobby for enabling county level policies, legislation or guidelines for HIV and TB response - Mobilise and allocate adequate resources for HIV and TB response - Include PLHIV representatives in the county decision making hierarchy
Entrench good - Build capacity of partners for resource management and CHMT governance accountability through institutionalised technical support and strengthen mechanisms CHTC multi-sector and - Build capacity of stakeholder networks of faith communities, multi-partner civil society, key populations and persons living with HIV and TB Partners accountability patients to promote strong accountable institutions that hold for delivery of duty bearers accountable for the HIV and TB response CEC Health MCHTSP results - Strengthen development partners HIV and TB forum focusing on alignment of activities to MCHTSP priorities Private sector - Develop and implement a partnership accountability mechanism based on targets and results for sub county level interventions - Review reporting mechanisms to leverage on regulatory institutions in order to capture private sector contribution to the HIV and TB response - Reform performance contracting to facilitate target setting and align sector reporting to MCHTSP results against targets
Strengthen Establish and - Establish a County HIV and TB Committee (CHTC) CEC Health functional and strengthen - Establish and support County Interagency coordinating competent functional and committee (ICC) HIV and TB competent - Establish and support County MCHTSP monitoring committee co-ordination HIV and TB and TB committee mechanism co-ordination - Establish and support Sub-county HIV co-ordination mechanism committees
54 Monitoring and Chapter 5 Evaluation Plan
5.1 M&E systems 5.3 Baseline Information Monitoring and Evaluation is an essential component Given that this strategic plan proposes to decrease of programmatic success. However, there exists the number of new HIV and TB infections, baseline gaps in M&E systems in the County, more so, in the data will be used to set mid and end term targets. areas of HIV and TB prevention, human rights and For those indicators where County-specific baseline mitigation. Other challenges identified, include lack data is not available, the MCHTSP will be guided by of standardized and disaggregated indicators for national data. adolescents and young people, inadequate tools and guidance on monitoring behaviour and human rights 5.4 Indicators interventions, limited capacity in M&E, as well as data quality issues. A District Health Information System Monitoring at County level will be based on an (DHIS) exists for purposes of tracking interventions established core set of indicators against the in the health sector. Data collection for community- strategic directions of the Plan. These indicators will based intervention, workplace, TB and social be sufficient to provide an indication of effectiveness protection programmes use the COBPAR, workplace of the County response at a glance. All primary data reporting tools, TIBU and social protection reports contributing institutions will be expected to submit respectively, albeit with major technical challenges. required data to appropriate sub-system. The focus will largely be on inputs, processes and outputs. The County will also rely on outcome and impact level 5.2 Data Quality data from national surveys for some of the indicators. Challenges exist in the management of data quality as there is no standardization in the manner in which 5.5 MCHTSP Reviews data is maintained by the different sub-systems. While some services/facilities use electronic and/ Given the multi-sectoral nature of HIV and TB web-based systems, others still utilise paper-based/ response, there are varied data sources from diverse manual systems. Some developmental partners have stakeholders hence the need for quarterly and bi- in the past used separate parallel data collection tools annual stakeholders data review forums. Midterm and methodologies. The plan will seek to consolidate and end term reviews of the plan will be conducted the different systems into a single County M& E in 2017, 2019 respectively, led by the KASF/MCHTSP system that will be used by all parties in the County - M&E committee, with the support of consultants. response. A uniform system, coupled with capacity These reviews will examine accomplishments building and exchange of ideas, should significantly against expected results over the first two years, as improve the reliability of data produced. well as at the end of the plan period. These will be
55 important opportunities to review plan strategies establish M&E system which would feed into the and indicators and where necessary make evidence- national system. Data from different actors will be based adjustments to the interventions. collected using the existing data collection tools for each sector/actor. 5.6 Data Flow and Archiving Data from different subsystems will be consolidated into the County M & E systems. The County will
Figure 5.1: Data flow in County HIV and TB response
National Surveys (KAIS, KDHS, TB Prevalence Survey National M&E System MoT and County Research)
County M&E System on a DHIS platform
Data Cash Transfer School Workplace programme Information LMIS DHIS TIBU COBPAR Reports reporting Systems reports
Commodity Facility-based Community Cash-transfer School health Workplace Programs management intervention based programmes interventions interventions
Transport & County social MoEST MDAs Private Faith Actors County MoH & CSO & sector sector construction Partners Partners development
Beneficiaries Community, adolescent and Young People, PLHIV, Inmates, KPs, employees, PLWD, OVCS
56 Coordination and Chapter 6 Implementation Arrangement
6.1 Stakeholder Management and interventions and assigns responsibilities to various Accountability stakeholders. Stakeholders will be coordinated and held accountable by the County HIV and TB One of the guiding principles towards achieving the Committee. For the multi-sectoral engagement County HIV objectives is multi-sectoral accountability. and effective implementation of this strategy, the The success of the HIV plan relies on identification following roles and responsibilities are designed. It, and involvement of all the stakeholders at the however, recognizes that given the complex nature of community, MDAs, workplace, schools and health HIV and TB, strong collaboration, mutual ownership facility levels. The MCHTSP provides guidance for and accountability is required for effective response.
Table 6.1: Stakeholders’ roles and responsibilities
National agencies Roles and responsibilities
National AIDS Control Council - Coordinate the multi-sectoral HIV response in the country - Provide policy and guidelines for HIV response - Offer technical support to the County - Monitoring and evaluation of the country HIV response National TB, Leprosy and Lung Disease program - Provide guidelines in TB response - Offer support supervisor and trainings to the County - Carry out research and offer M & E to the County
NBTS - Supply safe blood products - Set up a satellite in the County
NASCOP - Continually improve the DHIS systems - Review, print and distribute data collection registers to capture emerging issue, e.g. adolescent disaggregated data. - Provide Support and technical assistance in implementing facility-based EMR system - Review and disseminate HIV guidelines - Ensure commodity availability KEMSA - Timely distribution of HIV and TB commodities to the County as per her needs. - Strengthen and improve LMIS
KEMRI and National Laboratories - Support the County in VL testing and sputum for culture - Expeditious relay of results
Prisons - Enhance infection control programmes - Uphold human rights of detainees
57 Stakeholders’ roles and responsibilities
County departments/Sectors Roles and responsibilities
County Department of Health - Champion County HIV and TB legislations - Scale up HIV and TB interventions targeting priority populations - Offer non-discriminatory HIV and TB services in health facilities - Use strategic information to inform programming - Resource mobilization for scaling up of interventions - Procure HIV commodities and infrastructures - Coordinate inter-departmental County HIV and TB committee - Ensure that HIV and TB line budget is not diverted to other activities
County Departments - Allocate appropriate resources per the work plans of line ministries and departments for HIV interventions - Streamline audit mechanisms to ensure efficiency and effectiveness of allocated funds
County Department of Agriculture - To provide leadership in integration of HIV and TB in livelihood programmes
County Department of Education - Ensure that the rights of infected and affected children are protected - Strengthen school health programmes to include life skills, drug adherence and abstinence - Put in place policies to keep boys and girls in school - Address stigma and discrimination in school/ college settings - Implement infection control in school/college settings - Initiate and sustain school feeding programmes
County Legislative Arm - Legislate appropriate policies and laws - Mobilize communities to participate in HIV and TB response
County Department of Youth and Sports - Integrate HIV and TB prevention care and treatment into sporting activities and other youth forums - Establish resource centres - Initiate sustainable IGAS for youths out-of-school young people
County Department of Labour and Social - Implement OVC social protection programmes Services - Incorporate TB and HIV into existing social protection schemes, including nutritional support platforms - Implement structural interventions that empower vulnerable populations, especially OVCs, PWD, youth and women,e.g IGAs
County Department of Tourism - Encourage free condom outlets in hotels, bars and lodgings - Incorporate HIV in internal and external training programme including tourists training institution - Promote HIV prevention in bars, hotel and lodges - Enforce laws that protect the minors in lodges and bars
County Department of Transport - Use public transport systems for HIV/ TB prevention and health promotion messaging
County Public Service Board - Ensure that all County Departments have HIV and TB related work-plan programmes
58 Stakeholders’ roles and responsibilities
Key partnerships Roles and responsibilities
CSOs - Actively engage in demand creation for HIV and TB services - Support adherence and defaulter tracing - Work as “watch dog” of the County Government to ensure accountability of results - Participate in the County budgeting process (MTEF) and resource mobilization - Educate communities on legal issues, rights and gender
Development Partners - Promote locally-owned programmes in a coherent manner - Promote and rely on the county M&E system - Advocate for and support the County initiatives for resource mobilization to sustain programmes beyond external funding - Strengthen County capacity and provide technical assistance for coordinated harmonized and evidence-informed HIV and TB response
Media - Scale up anti-stigma and discrimination campaigns - Encourage journalists to identify issues in HIV and TB - Support CSR of corporate media houses - Media monitoring of content (quality and up-to-date HIV and TB information) - Provide secondary data to complement sector data
Academic institutions - Undertake research in HIV and TB to inform County planning and decision making - Mainstream HIV and TB in curriculum development - Support HIV and TB trainings - Address stigma and discrimination in their settings - Offer psychosocial support to students and staff living with HIV and TB
Private sector - Prioritize HIV and TB response as CSR agenda - Invest in HIV and TB response programmes
Faith Sector - Offer psychosocial support to PLHIV and support to OVCs - Mobilize communities to access HTS, care and treatment services
6.2 County Committees approve County HIV and TB targets, approve County HIV and TB Plans/Strategy, present County HIV and Various committees with multi-sectoral TB budgets to Health Sector working Group and representations from technical experts, partners, County Assembly, receive and approve reports on networks of PLHIV, County departments, Faith County HIV and TB plan performance and routine sector, private sector and CSOs will be set up to M&E from County HIV and TB Monitoring Committee, provide coordination and oversight in the County HIV receive reports from the County HIV and TB ICC/ and TB response. These committees include: Stakeholder Forum and Receive and approve work- County HIV and TB Committee: The County plans and reports of Sub-county HIV committees. Executive Committee Member for Health will chair County HIV Co-ordination Unit: This is the NACC the County HIV and TB Committee. The County HIV County office and is the repository, point of reference and TB Committee will provide leadership, mobilize on HIV matters. It is the Secretariat office of the County resources, set the County HIV and TB agenda,
59 HIV Committee. It is responsible for coordinating the 6.3 Critical assumptions multi-sectoral HIV response. In the implementation of the MCHTSP 2015/16- MCHTSP Monitoring Committee: Chaired by the 2018/19, the following key assumptions are made: CASCO. Will provide M&E functions during the • Adequate funds will be made available in time. implementation of the MCHTSP • Political stability and security will prevail. Sub-county/constituency committees: Membership and functions will be guided by national field • All stakeholders including development operation guidelines. partners and non-state actors will be supportive. HIV and TB ICC: Its the primary forum for deliberating on HIV issues at the County. It will have membership • Political will and support will be sustained. drawn from County Government, CSOs, private • National agencies, County departments, sector, Network of PLHIV and partners. The CEC- private sector, CSOs, Faith sector and partners Health shall chair while the NACC will provide will respond positively and cooperate. secretarial role.
Figure 6.1: County Coordination infrastructure for HIV and TB delivery28
CountyCounty Government Government (Governor)(Governor)
County Executive Committee
County HIV County HIV and TB County Health Coordination Unit Committee (CHTC) Management Team (NACC) (Chair: Health CEC)
Sub-County HIV Coordinating Committees
TWG- TWG- TWG- TWG- TWG- TWG- TWG- KP PMTCT Research TB Commodities ACT Adolescents/Young People
28 Adopted from KASF 2014/15-2018/19
60 Risk and Chapter 7 Mitigation Plan
The Risk Management Plan serves to identify risks to prevent or mitigate them, the matrix becomes a with potential to impact on the successful outcomes reference document for both the funding mechanisms of the strategic plan as a whole. By identifying these and monitoring and evaluating the plan. risks and especially by presenting possible strategy
Table 7.1: Risk and mitigation plan
Risk Risk Name Status Probability Impact Risk Response Responsibility When Category (1-5) (1-5) Average Score Technological -Loss of data Low 2/5 4/5 3/5 - Install data back CEC Health Year 1- up Year 4
- Give user rights Inadequate Medium 3/5 2/5 2.5/5 Allocate money CEC Health Year 1- capacity to roll for training and Year 4 out EMR infrastructure
Sustainability High 4/5 4/5 4/5 County ownership CEC Health Year 1- challenges of and commitment Year 4 EMR in the 16 facilities supported by partners Political Displacement of Low 1/5 4/5 3/5 -Set up a Disaster CEC Health, Year 1- populations management kit CEC Finance Year 4
Operational Partner High 4/5 5/5 4.5/5 Establish HIV CEC Health, Year 1- dependency budget line in CEC Finance, Year 4 county budget Chair of health committee Uncoordinated Medium 2/5 2/5 2/5 Establish a county CEC Health Year 1- interventions coordinating Year 4 from various committee actors/partners
Herbalist and Medium 3/5 4/5 3.5/5 -County legislation CEC Health, Year 1 Faith healing on herbal medicine Chair Health to include vetting committee and licensing -Community empowerment in health decisions
61 Risk Risk Name Status Probability Impact Risk Response Responsibility When Category (1-5) (1-5) Average Score
Extraction of Low 1/5 1/5 1/5 Community Community Year 1- false teeth empowerment in strategy focal Year 4 practices health decisions office
Legislative Stigmatizing Medium 2/5 4/5 3/5 Technical CEC Health Year county HIV laws/ assistance of 1 & 2 legislations MCAs on HIV programming for sound policies/ legislations Lack /weak Medium 2/5 3/5 2.5/5 -Review of existing CEC Health, Year legislation legislation Chair County 1 & 2 Assembly Weak -Enactment of Health enforcement county HIV/AIDS Committee Act
-Strengthen enforcement of legislation
62 Costing and Chapter 8 Resource Mobilization
The finances to implement the MCHTSP have been service costs are included in the health budget rather estimated with the view of achieving the best within a than the HIV budget. resource-constrained setting. The County Resource Needs for this strategic plan period was calculated Data and assumptions using Stover - County HIV Resource model. The Epidemiological data used in the model are from the template utilizes EPI and programme data to form Kenya Country HIV estimates, 2014. This includes the baselines and projects the resource needs over programme data on coverage of PMTCT and ART a period of time. The model assumes that medical programmes.
Table 8.1: Baseline information utilized in this model
EPI and Programme Data Revised value Default value
HIV prevalence among 15-49 year old adults 5.6% 5.6%
Adults receiving ART 13,451 9,705
Children receiving ART 1,622 1,480
Number receiving PMTCT 703 825
Number receiving HTC 145,308 145,308
63 Table 8.1: Baseline information utilized in this model
Interventions Current Unit costs of service
Coverage Revised value Default value Units
ART 69.0% KSh 51,612 KSh51,612 per patient
PMTCT 50.4% KSh 1,748 KSh1,748 per mother/baby
HTC 27.7% KSh 513 KSh513 per person tested
Adolescent friendly services KSh 6 KSh6 per service
Key populations KSh 6,440 KSh6,440 per person reached
Behavior change KSh 138 KSh138 per person reached
Program support 15.5% 15.5% % of other services
Where: Default values = national level costs
Program costs are calculated as a percentage of other costs
8.1 Projected cost of HIV programming
Table 8.2 : MCHTSP resource needs
Resource Needs (Millions of Kenyan Shillings)
2015 2016 2017 2018 2019
ART KSh 768 KSh742 KSh 716 KSh 690 KSh 664
PMTCT KSh 1 KSh1 KSh 2 KSh 2 KSh 2
HTS KSh 39 KSh48 KSh 57 KSh 66 KSh 75
Condoms KSh 31 KSh34 KSh 38 KSh 42 KSh 47
Key populations KSh 5 KSh7 KSh 9 KSh 12 KSh 14
Behavior change KSh 115 KSh141 KSh 168 KSh 198 KSh 231
Medical services KSh 0 KSh0 KSh 0 KSh 0 KSh 0
OVC KSh 98 KSh111 KSh 111 KSh 112 KSh 114
Program support KSh 162 KSh171 KSh 174 KSh 177 KSh 181
Total KSh 1,219 KSh1,256 KSh 1,275 KSh 1,301 KSh 1,329
Note The model does not cater for estimated costs forTB Programming, training and capacity building, research, M&E, which will be determined by activity budgets.
64 8.2 Financing the MCHTSP requires contributions from County Government. Health is a devolved function. The County Development Partners and non-state actors Government has the responsibility to provide including the private sector, civil society and local quality health care services to her citizens. The communities will complement and supplement the responsibility for financing this MCHTSP therefore County allocations in HIV and TB response.
65 Annexe 1 Annexes Results Framework
Strategic Direction 1: Reduce new HIV and TB infections MCHTSP Service Indicators Baseline Data Source Mid Term End Term Results Delivery Area Target Target
Reduce new Annual Number of new adult HIV 1,193 County Estimate 2013 596 238 HIV infection infections in adults and children by Annual Number of new child HIV 65 County Estimate 2013 33 13 80% infections
Key population Percentage of new infections from 35%* MoT study ( 2008) 20% 15% Key Populations (Sex Workers, MSM, prison population, PWID)
Number of syringes distributed per 0 Partner data NA NA person who injects drugs by the needle and syringe program % of FSW reporting the use of 88%* PBS 90% 95% condom during penetrative sex with their most recent client Percentage of men reporting the use 77%* IBBF 80% 85% of a condom the last time they had anal sex with a male partner Adolescent Percentage of young women and 55% County Estimate 2013 28% 13% programme men aged 15-24 who have had sexual intercourse before age 15 Percentage of schools that provide 52% County MoE records 70% 100% life skills-based HIV education HTS Percentage of the population 15% DHIS - 2015 35% 50% counseled and tested PEP Number of Health facilities providing 50 DHIS 100 150 PEP services General Percentage of people aged 15-49 8.4%* KAIS 2012 6% 4% Population who had sexual intercourse with more than one partner in the last 12 months Percentage of people aged 15-49 37.7%* KAIS 2012 50% 75% who had sexual intercourse with more than one partner in the last 12 months and reported condom use during the last sexual intercourse
* National Data
66 MCHTSP Service Indicators Baseline Data Source Mid Term End Term Results Delivery Area Target Target Reduce new PMTCT Number of pregnant women 612 DHIS 2015 1000 1600 HIV infection attending ANC whose male partner in adults and was tested for HIV children by Percentage of infants born to 96% DHIS 98% 100% 80% HIV-infected women starting on cotrimoxazole prophylaxis within 2 months of birth Percentage of infants born to HIV 70% DHIS 80% 100% infected women who receive DNA- PCR test for HIV within 2 months of birth. Percentage of pregnant women who 100% DHIS 100% 100% know their HIV status (1ST ANC Visit). Percentage of HIV positive women 94% DHIS 2015 96% 100% who receive anti-retroviral to reduce risk of mother-to-child transmission (ANC- PMCT) Percentage of health facilities 86% DHIS 2015 93% 100% providing EID Percentage of clients who finished 38% DHIS 2015 42% 50% four ANC visits
67 STRATEGIC DIRECTION 2: IMPROVE HEALTH OUTCOMES AND WELLNESS OF TB PATIENTS AND PLHIV MCHTSP Service Indicators Baseline Data Source Mid End Results Delivery Area Term Term Target Target Reduce ART Program Annual number of HIV related 751 County Estimate 2013 638 525 AIDS related deaths (Adults) mortality by 30% Annual number of HIV related 145 County Estimate 2013 123 101 deaths (children)
Percentage of people diagnosed 84% DHIS 2015 85% 90% HIV positive linked with care within 3 months. Percentage of PLHIV receiving HIV 61% DHIS 2015 70% 81% care services. Percentage and number of adults 100% DHIS 2015 100% 100% and children enrolled in HIV care (15273) and eligible for cotrimoxazole prophylaxis currently receiving cotrimoxazole prophylaxis. Percentage of adults and children 64% DHIS 2015 70% 80% currently receiving ART among all eligible people living with HIV (using national criteria). Percentage of adults and children TBD DHIS 2015 85% 90% with HIV known to be on treatment 12 months after initiation of antiretroviral therapy (24 months, 36 months, 60 months). PMTCT Program Percentage and number of eligible 92% (1852) DHIS 2015 97% 100% clients newly initiated on highly active ART in the last 12 months. HIV/TB Co Percentage of TB/HIV co-infected 97% DHIS 2015 98% 100% morbidity clients who are receiving ARTs. Percentage of HIV patients 100% DHIS 100% 100% screened for TB. ART Program Percentage of ART patients with NO DATA DHIS 85% 90% an undetectable viral load at 12 months after initiation of ART Percentage of people on ART 41% NASCOP Report 75% 90% tested for viral load who have Dec2015 a suppressed viral load in the reporting period Capacity Percentage of health facilities 35% RHIS 40% 50% building providing HIV care and treatment services Percentage of health facilities 86% RHIS 93% 100% implementing continuous quality improvement activities according to MoH standardized protocols Number of health facilities 75 RHIS 86 107 providing care and treatment according to MoH standardized protocols
68 Strategic Direction 3: Use a human rights approach to facilitate access to HIV and TB services
MCHTSP Results Service Deliv- Indicators Baseline Data Source Mid Term End Term ery Area Target Target Reduced Stigma Stigma and Percentage of PLHIV who self- 49.2% Stigma index 35% 25% and discrimination discrimination reported that they experienced survey (2013) by 50% discrimination and/or stigma due to their HIV status Percentage of women and Men: 32.6%* KDHS 2009 75% 80% men ages 15–49 expressing Women: accepting attitudes towards 46.9%* people living with HIV General Percentage of ever married or 6.6%* KDHS 2009 3% 0% population partnered women and men ages 15–49 who experienced sexual and/or gender based violence KP Percentage of MSM who 24%* IBBS 15% 10% experienced sexual and/or gender-based violence Percentage of sex workers 44%* IBBS 25% 10% who experienced sexual and/or gender-based violence OVCs Percentage of OVCS reached 31% County 50% 75% with social protection estimate programs
* National Data
69 Strategic direction 4: Strengthen integration of health and community systems MCHTSP Results Service Indicators Baseline Data Source Mid Term End Term Delivery Area Target Target Adequately staffed Health Care Ratio of cadres of health care 1.69/1000* 2.0/1000 2.4/1000 workforce Workforce staff to population in line with staffing norms Improved access to Commodity Percentage of health facilities 62/223 (28) RHIS 32% 35% HIV commodities Management providing KEPH defined and services HIV&AIDS services Percentage of health facilities 0 RHIS 0% 0% dispensing ART that experienced a stock-out of ARVs at least once in the last 12 months Strengthened Community Number of community units 9 County Focal 20 50 community Units implementing AIDS competency office service delivery guidelines of HIV prevention, Community Number of Community Health 9 County Focal 20 50 treatment, care Based Units given training on HIV office and support Organizations module
Number of Community Health 9 County Focal 20 50 Workers reporting on HIV office programmes Number and percentage of 47%* COBPAR 75% 80% community-based organizations that submit timely, complete, and accurate reports according to guidelines Health Systems Health Systems Number of health facilities 32 RHIS 40 50 Strengthening Strengthening providing integrated HIV services
Number of health facilities 214 RHIS 214 214 implementing universal precautions to prevent HIV infection
70 Strategic direction 5: STRENGTHEN RESEARCH AND INNOVATION TO INFORM MCHTSP OBJECTIVES MCHTSP Re- Service Delivery Indicators Baseline Data Source Mid End Term sults Area Term Target Target Adequately Build Capacity for Number of prioritized research 0 2 4 staffed workforce Research conducted
Number of people trained in 0 10 20 HIV related research
Funding for Number of HIV related studies 0 2 4 Research undertaken at postgraduate levels in tertiary institutions
Proportion of HIV funds utilized 0* KNASA 5% 7% on research Increased Application of Percentage of research TBD 100% 100% evidence based research finding in products disseminated to planning and decision making inform policy, planning, and programming programming
Strategic direction 6: PROMOTE UTILIZATION OF STRATEGIC INFORMATION FOR HIV AND TB PROGRAMMING MCHTSP Service Indicators Baseline Data Source Mid Term End Term Results Delivery Area Target Target Increase Increase access Number of planned M & E - RHIS 8 16 availability and strengthen reports generated of strategic to Strategic information information Percentage of planned M & E - RHIS 100% 100% to inform HIV reports disseminated response Established and functional 0 1 1 MCHTSP /KASF monitoring committee
Number of sub counties 6 6 6 submitting timely, complete and accurate reports Percentage of implementing - 90% 100% partners reporting through DHIS
SD 7: INCREASE DOMESTIC FINANCING FOR SUSTAINABLE HIV AND TB RESPONSE
MCHTSP Re- Service Deliv- Indicators Baseline Data Source Mid Term End Term sults ery Area Target Target Increase domestic Government Establishment of specific 0 1 1 financing to 50% funding budget lines and funding for HIV
Percentage of government 17%* KNASA (2014) 30% 40% funding for the HIV response
* National Data
71 Strategic direction 8:
PROMOTE ACCOUNTABLE LEADERSHIP FOR DELIVERY OF MCHTSP RESULTS BY ALL SECTORS AND ACTORS
MCHTSP Service Indicators Baseline Data Source Mid Term End Term Results Delivery Target Target Area Increase Establishment County HIV coordinating SCACCs-6 RHIS SCACCs-6 SCACCs-6 domestic of coordination committees in place financing to framework 50% County HIV County HIV County HIV and TB and TB and TB Committee-0 Committee-1 Committee-1 Percentage of county MDAS 0 Public sector 90% 100% with result based HIV plans reporting tool aligned to MCHTSP
72 TB INDICATORS
MCHTSP Service Indicators Baseline Data Source Mid Term End Term Results Delivery Area Data Target Target Increased case Case notification Number of TB patients reported 1606 (82%) TIBU 2014 84 85 notification of to the National TB program. new TB cases to 85% Percentage of TB case 0.8 TIBU 2014 5 10 notification referred by CHWs
HIV TB co Percentage of TB cases offered 0.2 TIBU 2014 2 4 infection DOT by CHWs
Percentage of all registered TB 97 TIBU 2014 98 100 patients tested for HIV
Percentage of TB/HIV co- 99 TIBU 2014 100 100 infected on CPT
Percentage of TB/HIV co 96 TIBU 2014 98 100 infected on ART
Percentage of HIV TB cases 75.5 TIBU 2014 80 95 whose partners were tested for HIV Percentage of HIV patients 29.2 TIBU 2014 50 80 initiated on IPT
IPT Percentage of children under 18 TIBU 2015 30 50 5yrs exposed to smear positive TB initiated on IPT Treatment TB outcomes Percentage of TB patients 26 TIBU 2014 40 60 success of offered nutritional support at least 95% among all Drug Treatment success rate 92 TIBU 2014 94 95 Susceptible (DS) forms of TB Cure rate 90 TIBU 2014 94 95
73 MCHTSP Drafting team
Name Organization
Dr. Pius Mutuku MoH
Dr. Kasanga MoH
Dr. Virginia Karanja ICAP
Justus Muinde MoH
Laurene Mwende NEPHAK
Jasper Kituku MoH
Nelson Mbithi MoH
Medrine Ngila MoH
John Kangwele MoH
Ruth Kinyua AHF Kenya
Marietah N. Peter MoH
James Munguti MoH
Joseph Kavoi MoH
Technical Review Team
1. Stephen Malai - Reality Media 2. Alfred Kibunja - Carlene Consult 3. Catherine Mutuku - NACC 4. Peter Kinuthia - NACC
74 Location Map of Makueni